Under Pressure...

It’s just before 5pm on an evening when I was on call. I stroll down into theatres from the day-case unit to pick up the cardiac arrest bleep and try and find Anita, the anaesthetic SHO on-call for the daytime, to get a handover.

As I’m walking down to the main operating theatres, Sharon, one of the senior theatre nurses, walks up to me and says, “Michael, are you on call this evening?”

“Yes. Why? What’s going on?”

“You’d better get to the Emergency Theatre, that patient from this morning is coming back.”

I have no idea what she’s on about, I haven’t been in main theatres all day but there are lots of people rushing around with bits of equipment so I guess something major is happening.

“What patient?” I say to Sharon’s disappearing back.

“Leaking femoral artery graft” replies Sharon over her shoulder and she vanishes round the corner.

Oh shit.

This is very bad news indeed. I go to the emergency operating theatre and find Anita who tells me that the patient had an attempted stenting of his right femoral artery in the morning but is being rushed back to theatres because the stent is leaking, that is blood is leaking from the patient to the floor. You don’t have to work in a hospital to realise that this is a BAD THING INDEED.

The Emergency Operating Theatre is a flurry of activity. There are about a dozen people inside setting up bits of kit, opening boxes and getting things ready. As I’m talking to Anita, two of the surgical registrars run past us and I’m told that the vascular consultant is on his way.

“How do you want to do this?” asks Atul, one of the Operating Department Assistants.

“Let’s not mess around in the anaesthetic room,” Anita replies. “We’re going to go straight through to theatres and we’ll anaesthetise him there whilst the surgeons are prepping.

Just then, the patient comes round the corner. He’s on a bed, being pushed by two porters. One of the staff nurses from the ward is pressing a pad onto his groin, but despite her best efforts, blood is leaking from around her hands and is collecting in his bed in a big, crimson puddle on the bed. The bedsheets are saturated red and blood is dripping onto the floor as the patient comes towards me. The patient already has a central line from the morning’s operation and a petrified-looking Year 1 surgical doctor (FY1) is squeezing a bag of blood into the patient’s central line whilst a student nurse is squeezing some more fluid in through a drip.

“Oh, shit,” I think to myself. As the enormity of the situation unfolding in front of me hits home, I notice my heart is hammering inside my chest and my mouth has gone so dry that it hurts to swallow.

It’s at this point that Anita looks at me and asks, “Do you want to do this one?”

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I’m going to pause this story for a second and explain a couple of things about being a novice anaesthetist. This situation is my worst nightmare. I need to anaesthetise the patient RIGHT NOW because without the operation RIGHT NOW, he’ll die. If I can’t anaesthetise him, the surgeons can’t operate and he’ll die. I’ve never met the patient and know nothing about him so I really have no time to plan my anaesthetic, I’m just going to have to get on with it, fly by the seat of my pants and hope that it turns out OK.

Anita is a year more experienced than I am, and I’m sure that she could handle the situation. The question she was really asking me was “Do you think you’ll be able to cope with this?”

I’ve been working in anaesthetics and intensive care for five months now. This is long enough to know what I SHOULD do in the situation, five months is long enough to be painfully aware of what will happen to the patient if I get it wrong and can’t deal with it, but I’ve not yet had to actually deal with a situation like this it myself. The old cliché goes, theory and practice are two very different animals.

In my head, I know that if I want to be an anaesthetist, it’s in exactly this sort of situation that I have to stand up and be counted. I have to show the “leadership” and “calmness under pressure” that they kept asking me about in my interviews for the job. So despite my sacredness, my self-doubt and my misgivings, I look Anita in the eye and say:

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“Yes.”

She smiles and says, “Good. OK, he’s all yours.”

As they push the patient, Mr Jones, into the anaesthetic room, I say “Go straight through to theatres, I’ll anaesthetise him in there.”

Mr Jones is actually in better shape than first impressions would suggest. He’s conscious, lucid and is actually probably the calmest person in the room. I don’t think that Mr Jones had any doubts in his mind that the good old NHS would be able to sort him out.

I help shift him onto the operating table, which was actually quite difficult to do – the staff nurse loses her grip on Mr Jones’ groin for a second and a spurt of his blood goes straight up in the air like a scarlet fountain.

Once he’s on the operating table, people start connecting ECG monitors, blood pressure cuff etc…

“Hi there Mr Jones, my name is Michael. I’m the anaesthetist and I’m going to put you sleep in a couple of minutes. How are you feeling?”

“Not too bad.”

“Do you understand what’s happening?”

He nods.

I turn on the anaesthetic machine and put the oxygen mask onto Mr Jones’ face.

“Could you hold this for a moment please, sir.” As Mr Jones takes hold of the oxygen mask, I dash back into the anaesthetic room and get my drugs.

I quickly find the Thiopentone and the Suxamethonium and walk back into the room.

“What’s his blood pressure?” I ask.

“168/73,” comes the reply. Good, he’s got a decent blood pressure, which means I have a few minutes to play with. I decide to get a little more information as I’m mixing the drugs.

“Have you had any problems with anaesthetics in the past, Mr Jones?” I enquire as I squirt the saline solution into the vial of Thiopentone.

“No, not really.”

“Do you have any allergies” I give the vial a shake to dissolve the drug

“Not that I know of”

“How much do you weigh?”

“Ooh, about eleven and a half stones”

Right. Here comes the maths part.

I have 500mg of Thiopentone drawn up into a 20ml syringe. One of the facts I’ve remembered during my evenings is that the dose of Thiopentone needed to send someone to sleep is 5-7mg per kilo, though this is often less in elderly people like Mr Jones. This man weighs 11½ stones. I’ve remembered that this is about 75kg. How many ml of Thiopentone shall I give him? Too little and I won’t anaesthetise him properly, this means I won’t be able to intubate him which will mean we can’t start surgery and he’ll bleed to death. Too much and I’ll overdose him, I’ll obliterate his blood pressure and I’ll never be able to get it up again - he’ll have a cardiac arrest and die.

I spent many an afternoon in watching Countdown in my early teens and I was thankful to those afternoons for honing my mental arithmetic skills. I work out how much Thiopentone and Suxamethonium I’m going to give Mr Jones and put the syringes on the anaesthetic machine.

It’s time to start the rapid sequence induction

“OK, Mr Jones, we’re ready to go. I’m going to hold this mask on tightly onto your face now and I’m going to hold it for three minutes. Then I’m going to send you off to sleep. Just as you’re drifting off, Atul here is going to press on your neck, just here. Don’t be worried or think that we’re trying to strangle you; it’s just that this is the safest way to send people to sleep in a situation like this. Is there anything you want to ask me?”

“No,”

I press the oxygen mask onto his face.

I never appreciated how long three minutes can sometimes seem. I look around. The surgical registrars have scrubbed up and have got the drapes onto Mr Jones’ leg. I see the vascular consultant rush into the room with one of the theatres staff behind him, trying to do up his gown as he rushes towards the patient. He looks at me.

“I’m just about to send him under,” I tell him and he nods while his registrars prep the surgical site.

One minute has passed.

Slowly everyone in the room slows down what they are doing and more and more eyes turn to me. They can’t start until I put Mr Jones to sleep. I have to do this now or Mr Jones will die and I’ll forever have his coffin resting on my conscience. I’m properly bricking it, but I’m trying my best to appear calm and stop myself from physically shaking.

I briefly remember an episode of Scrubs where JD is having trouble dealing with emergency situations. He asks Elliot how she manages to cope and she replies, “Just breathe… deeply… and slowly… and you’ll find that you do have more time than you realise.”

I take her advice and take three, deep, slow breaths.

Two minutes have passed.

I ask someone raise the bed for me. I ask someone to turn on the Yankauer sucker and put in near my right hand. I ask Atul to show me the light on the laryngoscope blade. I look at the clock and three minutes are up.

“OK, here we go, I say. I’ll see you when you wake up, Mr Jones.” He nods at me.

“Cricoid pressure on please, Atul.” I inject 14ml of my Thiopentone solution into Mr Jones’ central line and follow this with 1.5ml of Suxamethonium.

Mr Jones’ muscles ripple and contract as the Sux kicks in.

“Fasciculations,” I say, though I’m not sure who I’m talking to. It’s probably to reassure myself as much as anyone else.

“Scope, please.” Atul hands me the laryngoscope and a slide it into Mr Jones’ mouth. I’m vaguely aware that the room has gone quiet, but I’m acutely aware that I can’t see what I’m looking for. I use my right hand to pull on Mr Jones’ top teeth to open his mouth more and tip his head back. I push the scope further into his mouth. “Breathe…” I say to myself. The epiglottis comes into view and I push the tip of the blade into Mr Jones’ vallecula and lift his tongue up with the scope. “Breathe…” His vocal cords come into view, more or less… and I decide my view will have to do.

“Tube, please” Atul passes me the endotracheal tube and, thankfully, I’m able to push it through Mr Jones’ vocal cords and into his trachea.

“OK, I’m in.” I can now use my anaesthetic machine to breathe for Mr Jones and keep him asleep for the operation. I pull the scope out of Mr Jones’ mouth while Atul inflates the cuff. I double and triple check the position of the tube, start the ventilator and tell the vascular consultant.

“You can start now”

The hard work was done.

Over the next hour or so of the operation, I organised transfusions and infusions, put in an arterial line and made sure we gave Mr Jones the best possible chance of surviving.

Mr Jones went to the Intensive Care Unit after the operation and I went home feeling very, very pleased with myself indeed.

- Michael.

Heard around the hospital...

Unsurprisingly, after the application process for 2008 began last week, MMC was the talk of the hospital today.

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One of the ENT surgical registrars ponders MMC:

“The thing is; I just don’t understand the point of it all. I mean, let’s face it, doctors are generally nice people. We’re a clever bunch and we all work hard. We study hard to pass all our exams so we know the right things to do for our patients. We all work countless extra hours for free because we care for the people we look after. I don’t get why they [the employers] don’t just treat us like decent human beings. Why do they keep making us reapply for the jobs we’re already doing? Why are they making us move to different parts of the country every 12 months? Why do people have to leave the country to train? At the end of the day, we want to be trained so we can better look after our patients, so why are they making that so difficult for us to do? I don’t understand.”

A text message from a friend doing paediatrics:

"I'm having a mare! I can only apply to 2 deaneries and I'm getting stressed. Send me a joke to cheer me up..."

A fellow anaesthetics doctor:

"I spent the entire weekend doing those bloody forms. They just take forever, they end up just sucking all the hours of the day away - and my spirit with it!"

SHO in Trauma & Orthopaedics

"You are so lucky that you don't have to do this, you know"

Yes, I do know, and I really appreciate how fortunte I am.

A bad experience (part 2)

“Michael, you can anaesthetise the next patient by yourself, if you need me, I’ll be in the Departmental Offices.”

“Sure,” I reply and with that, my consultant turns on her heels and disappears round the corner and down the corridor.

I’ve got to the stage now where I feel confident to administer simple anaesthetics by myself. I’d already met the patient, Mrs Romano, before the operating theatre opened and aside from her being very nervous, I found nothing that would suggest I’d have any major problems giving her an anaesthetic.

Mrs Romano is the third patient on the list this morning. She’s having a shortish operation, so I plan to anaesthetise her, use a laryngeal mask airway (LMA) and allow her to breathe for herself.

“Hello again,” I say as she walks into the anaesthetic room. When I met Mrs Romano first thing in the morning, I thought to myself “this woman couldn’t BE more nervous.” I was wrong. Now, Mrs Romano is almost crawling up the walls so I decide the best plan is to get going with minimum delay. She takes a seat on the trolley and Danny, the ODP performs all the safety checks. We are good to go.

I’ve already prepared all the drug that I want to use and I pop a drip into the back of her hand. I then give her the oxygen mask to breathe and start injecting the drugs to render her unconscious. First I give Midazolam to calm her, then Fentanyl as a pain killer and finally, Propofol as the induction drug.

Very nervous people tend to require higher doses of drugs, so I’m a little surprised when Mrs Romano goes out like a light. I gently breathe for her using the oxygen mask and bag, and slip the LMA down her throat. It goes in easily and sits nicely. So far, so good. Danny and I wheel Mrs Romano into the operating theatre where the consultant surgeon and the theatre staff are waiting to start the operation.

Everything goes smoothly, I fiddle a little with the anaesthetic machine halfway through, but at no point am I concerned that Mrs Romano is going to come to any harm.

When the operation is over, I wake her up again and we go through to the recovery area where the nurses make sure that she is OK before sending her back to the ward.

All in all, a pretty uneventful anaesthetic – just the way it should be.

I like to go see my patients at the end of every day. I know a lot of anaesthetists don’t do this, but I like to make sure that everyone is OK and that there was nothing that happened that they were unhappy about.

Mrs Romano is in a bay with three other ladies. She looks up and smiles when she sees me approaching.

“Hello there!” I pipe up

“Hello,” she beams back

“How are you feeling?”

She grabs my hand and says “I feel great, doctor.”

“No pain? No sickness?”

She shakes her head

“Have you had something to eat and drink yet?”

“I’ve had a cup of tea, but all they’ve given me to eat is this,” she gestures distainfully to a single, dry piece of bread with no butter “and I don’t really fancy it.”

“Well, I don’t think the NHS is known for the quality of its cuisine,” I reply and she laughs “but hopefully you’ll go home later on today. Now, can I ask you one more question?”

“Certainly”

“Do you remember anything about the operation?”

“No, nothing at all. I remember coming down and talking to you but that’s it really.”

“So, really, Mrs Romano, the anaesthetic is not as bad as you thought it was going to be was it?”

“Oh no, not at all! Thank you so much. I was petrified about this operation, you know. I almost rang up last night to cancel it because I was so scared, but my husband made me come (I resisted smirking when she said this). But it was fantastic. You know, the reason I was so scared was because I had a bad experience with anaesthetic before.”

“Really?”

“Yes, I was six years old and I had to have an anaesthetic so the dentist could pull one of my teeth out. Back in those days, anaesthetic were very different. They go me in the chair and they had this wire mask with a bit of cloth in it. And what they did was they dripped the anaesthetic stuff onto the cloth and held it onto my face.

“It was horrible. I couldn’t move, the stuff was stinging my eyes and I couldn’t breathe. Do you know what I thought doctor?”

“No.”

“I thought they were trying to kill me. I thought I was going to die. I remember trying to get away, but I couldn’t move. I tried to shout for my mother but I couldn’t. I couldn’t do anything. I know this probably lasted for a couple of minutes, but, to me it seemed to go on forever.”

“Oh. That sounds awful!”

“It was. And remember, I was only six years old. So you see, that was why I was so scared this morning. I know that happened more that fifty years ago, but to this day I can’t stand having masks or anything on my face.”

I take a deep breath and sigh. “Well, you’ve seen for yourself that anaesthetics have come a long way since those days.”

“Oh they have!” She emphasises. She still holding my hand and she gives it a squeeze. “Thank you so much for everything you’ve done for me.”

“You’re very welcome, Mrs Romano. I wish you all the best. Take care.”

- Michael

Stick

I’ve made up my mind and I now have a plan.

Thank you all for your advice – I’ve decided to stay where I am (for now).

I’m doing a job I really enjoy but have a seven year contract in a city that I really dislike. I’ve been trying to decide whether I should apply for another training job elsewhere in the country and give up my training contract where I am.

A couple of weeks ago, I had pretty much made up my mind that I was going to leave this to seek work elsewhere, but now I’ve changed my mind and the reasons are as follows.

The Royal College of Anaesthetists have always said they thought that some changes to anaesthetic training made by MMC were a crock of shit. Specifically, they didn’t agree with idea of a 7-year “run-through” training programme (this is the type of contract that I currently hold) and, backed by the Tooke Report, they’ve decided to get rid of this. Those, like me, who managed to get a “run-through” job in 2007 will have their contracts honoured, but there will be no more 7-year training programmes offered. Instead, training will be “decoupled” and split into two consecutive 2- and 5-year contracts. Doctors would have to reapply at the end of the 2-year “basic” training part. The idea is that it gives doctors in training a chance to change locations or specialties part-way through their training.

In a nutshell, the abolition of “run-through” training gives me an opportunity to move to a different part of the country in 2009 and this is what I plan to do. I’m going to stay here in NewCity for another year and then apply for registrar (ST3) jobs elsewhere next year.

Last year, the application process made my life a misery for months and months and the thought of doing it all again now makes my heart sink – especially as competition for places is going for be even fiercer this year.

It won’t be plain sailing though. In order to be eligible to apply for jobs starting August 2009, I’ll need to have passed both parts of the fiendishly difficult anaesthetic post graduate primary exams before January of next year. Because of the timing of the exams, this means that I’ll have to pass both sections on my first attempt, plus I’ll have to sit the first part after only a few months of anaesthetics. It’s going to be a huge ask but I think that the prize of Escape from NewCity will spur me on to study harder than I’ve ever studied before!

So, it seems I’ve found the “3rd way” as a solution to my problem. I’m going to stay put for another year and aim to leave next summer. This means that I won’t have to stay in this crap city for the remainder of my youth, but at the same time, I won’t have to navigate the medical job application system four times in four years either. The down side is that I’ll spend most of the next 12 months in the library studying like a fiend.

In the meantime, I’m going to follow the advice of some readers to this blog. I’m going to get a new hobby or two, get a girlfriend, kick back and appreciate what I have achieved so far. After all, I’m doing something I love every single day and getting paid for it.

Now, how many people can honestly say that?

- Michael

A bad experience

“Good morning, Mrs Romano. My name is Michael and I’m one of the anaesthetic doctors. It’s my job to put you to sleep for your operation today and to wake you up again afterwards. How are you feeling today?”

She shrugs and grunts at me

“Had better days, yeah?”

“Something like that. I’m really nervous”

She didn’t need to tell me this. She was obviously very scared. She was twitchy, she only made fleeting eye contact and she was gripping onto the side of her chair so hard that her knuckles were turning white.

I do my best to put her at ease while I take an anaesthetic history from Mrs Romano and examine her. She’s pretty fit and well and there is nothing that would lead me to expect any problems with the anaesthetic. I then give my usual “what happens when you have an anaesthetic” speech and ask if there’s anything she unsure of or wants to ask me.

“Not really,” she replies.

“Is there anything in particular that you’re worried about?” I press.

“It’s just… It’s just the lack of control isn’t it? I’m scared I’m not going to wake up again." With this, she bursts into tears.

I’ve only been an anaesthetist for a few months, but being afraid of not being in control is something that my patients tell me time and time again. It’s a very valid concern. Having an anaesthetic is a very weird thing and by consenting to it, you are putting your ability to feel things, your ability to think, your ability to breathe and literally your life in the hands of someone you’ve just met (me). I know that some may say that anaesthetists do fuck all, but in reality, giving a general anaesthetic is a colossal responsibility and literally people’s lives depend on me being switched on enough to sort out any problems that may occur before, during and after the operation.

I fetch Mrs Romano a tissue and give her a moment to recompose herself. “I understand how you feel,” I say. “Having an anaesthetic isn’t something that happens every day is it? And I know that you are putting an incredible amount of trust in me. Please remember though, that I do this every day. I stay right next to you the whole time you’re asleep. I never leave you side and I promise to look after you. If it helps, I could go through the risks of what might go wrong. The chances of something going badly are very small indeed, especially as you’ve had anaesthetics in the past and have been OK with them. Would you like me to go through the risks with you?”

She nods and I go into my “risks of general anaesthesia” speech and ask her if there was anything that she’d like me to clarify.”

“No, not really,” she replies. “I sort of just want it to be over as soon as possible.”

I give a half smile and say, “well, it won’t be much longer now. I imagine they’ll come to collect you at about an hour and a half. I’ll see you downstairs Mrs Romano.”

“Yeah, sure” she grunts, “I’ll see you later.”

To be continued…

The Tooke Report

If I were a Victorian war novelist, this is how I would end one of my books…

The dust has settled, the bodies have been counted and the smell of cordite no longer assails the senses. The old general regards the battlefield and sheds a tear as he thinks of how much was lost fighting another man’s cause. One thought revolves around and around his battle-wearied mind like a moth slowly circling an oil-lamp:

“What was the point? For what did we sacrifice so much and achieve so little?”

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The Tooke Report (the independent inquiry into the MMC fiasco) came out today and here’s what it said…

"The structure of postgraduate training proposed by MMC is unlikely to encourage or reward striving for excellence, offer appropriate flexibility to trainees, facilitate future workforce design,
or meet the needs of particular groups (e.g. those with academic aspirations, or those pursuing a non-consultant career grade experience). It risks creating another ‘lost tribe’ at FTSTA level."

It just begs the question… What was the point of MMC? For what did we sacrifice so much and achieve so little?

Stick or Twist? A New Year's Dilemma

Happy 2008 to one and all.

The New Year marks a time for new beginnings, new hopes, new aspirations and, in my case, a huge new dilemma. It won’t come as a surprise that my dilemma is, once again, related to MMC. For those who don’t know, MMC (Modernising Medical Careers) was the government’s attempt at reforming medical training. The idea was that doctors would get a clear career path and a structured training schedule. It’s failed, all that the government succeeded in doing was fucking up the lives of thousand and thousands of junior doctors, created endless reams of extra paperwork for us to do (taking us away from our patients) and the “training” is exactly the same as before – the big difference is that we now have less of it.

Not exactly progress, if you ask me.

The failings of MMC and last year’s MTAS fiasco have been discussed no end on the web, in the papers, on the radio and on the telly, so I won’t go into all that again but I will explain to you the dilemma that MMC has left me with and maybe you guys can help me out.

Last summer, I was working as a doctor in general medicine and MTAS/MMC fiasco left me staring down the barrel of unemployment. With only 9 days to go until I had to sign on to the dole, I managed to secure a “run-through” ST1 job doing anaesthetics in a different part of the country. “ST” jobs were like gold-dust and the competition for them was fierce, so I was very pleased to be offered one and accepted the job offer with much relief.

I then relocated myself to a different part of the country, found myself a lovely apartment to live in, and set about seeing if a career in anaesthetics was for me. After working here for 5 months now, I love my job. I find it the most interesting, exciting and rewarding job that I’ve ever done and I KNOW that this is what I want to do for the rest of my working life.

So far, so good and you may now be wondering what my dilemma is.

I’ll tell you. It’s this city. I really enjoyed where I was living before but my new city (NewCity) just doesn’t have the vibrancy, the character and the things I enjoy. My first impressions of NewCity were that it was ugly and uninteresting and, after living here for almost half a year now, I know that my first impressions were correct. NewCity is just a bit rubbish really. Entertainment comes from the “Let’s Go Out, Drink 12 Pints, Dance To Cheesy Music And Try To Get Off With A Slightly Overweight Bird” school of good times. I’ve nothing against this once in a while, but my problem is that there is NOTHING ELSE to do here and the “living for Saturday Night” mentality gets a bit tedious after a while. I don’t know – maybe I’m just getting old!

Another part of the problem, I feel, is that I am now living hundreds of miles away from my family and old friends. This isn’t as huge a deal for me as it is for some people because I’m pretty good at making the effort to visit people or call people. Also, I’m a pretty affable and sociable person and tend to make new friends quite easily. That said, I’m not at the “popping round unannounced to your mates house to watch the footy” stage of friendship yet, and I think I miss that a little too.

So my dilemma is this. Should I stick with NewCity? As things stand, I have a seven year Specialty Training contract here. The fact that I’m doing a job I really love and have found a gorgeous apartment to live in would suggest sticking with it. But then again, should I remain in a place I don’t like for seven years (the rest of my youth)?

Leaving would mean giving up my run through training and I’d have to navigate my way through the quagmire of the applications process once more. There is even more competition for training positions this year than there was last year, so if I decide to leave, there is a real chance I won’t be able to get another job and end up being unemployed.

The 2008 application process began on Saturday, so I have to make a decision pretty quickly.

Should I stick or should I twist? I really am torn, what do you guys think I should do?

- Michael

b.t.w. the system does not allow me to transfer my contract to another part of the country because my reasons for wanting to move are not “compelling” enough.

Season's Greetings

I wish you all a very Merry Christmas and all the best for the New Year

- Michael

Creature of the night

My theatre list finished early today and I was lucky enough to leave work by about 4pm. I got changed, picked up my bag, my coat and my books and headed outside. As soon as I stepped out of the door, I almost took a step back. It took me a couple of seconds to realise what had startled me, but then it became obvious.

It was the twilight. In that moment I realised that I hadn’t actually seen any daylight at all since Sunday afternoon. I wake up in the darkness and it’s still dark by the time I get to work. I spend the day in the operating theatre where there are no windows and by the time I’ve woken up the last patient of the day, it’s dark again, so I don’t get to see the sun he I go to see my post-op patients on the ward.

I’ve become a creature of the night and I don’t really like it. Is it too early to start looking forward to summer?

Where have all the doctors gone?

Last week, New Town anaesthetics department had its “Junior Doctors Forum.” This is basically a place where we juniors get to say what I working well and what is not working well within the department.

Unsurprisingly, straight out of the gate was the state of the on-call rota. Basically, there aren’t enough junior doctors to fully staff the rota. This means that we are constantly being asked by medical staffing to do extra shifts. The consultants frequently have to carry the on-call and cardiac arrest bleeps and the hospital trust is having to fork out huge sums of cash to pay for locums (it costs the hospital £3185 to pay for a locum anaesthetic registrar to cover a week of night shifts). The problem is going to be even worse in the new year, when a couple of the more senior SHOs leave to take up registrar position elsewhere in the country.

In the meeting someone asked if there were any plans to employ more juniors and the reply I got was something like this.

“We’re trying. We’ve had a couple of adverts out for a while now, but we only had one applicant and that person pulled out of the interview last week.”

I was flabbergasted. When I applied my job as a Medical SHO, human resources told me they received nearly 900 applications for 2 positions. Now, a couple of years later, they can’t even attract a single applicant? It begs the question – where have all the junior doctors gone?

The answer is obvious isn’t? It’s another legacy of MMC and the MTAS fiasco.

On the face of it, you’d have thought that a shortage of junior doctors was never going to be a problem. In January of this year, there were 33 000 doctors simultaneously applying for only 21 000 jobs and we junior doctors were fretting about unemployment - indeed I came within nine days of the dole queue.

It seems that what’s actually happened is that the suits at the Department of Health and the MMC have seriously overestimated how much shit junior doctors are willing to put up with.

What is now becoming apparent is that thousands of us have “Just Said No.” This has led to a mass exodus of junior doctors from the NHS. I personally know of 13 doctors of a similar experience level to myself that have left the NHS this year. Multiply that across the nation and you’re talking of a huge number of doctors who were simply unwilling to be treated in such an unfair and callous way. I think Dr Rant hit the nail on the head with this post.

The funny thing is, not one of my friends who have left the NHS regrets their decision. Whether they’ve gone to work abroad, or just given up being a doctor completely to do something else, it seems that they’ve found working conditions far better outside the NHS and, as things stand, none of them have any intention of coming back.

Nurses

Yesterday, I was on call for anaesthetic emergencies with Jim, one of the slightly more senior anaesthetic trainees. The surgeons wanted to operate on a man in his eighties who had come into hospital with bowel obstruction. When we went to see him, it was obvious that this man had so many other medical problems that if he would need to go to intensive care after the operation to give him the best chance of surviving the surgery. Jim, myself and the ward sister were in the process of organising this man’s post-operative care. Despite obviously having lots to do, this nurse was doing the best she could to help us set things up so our patient could have his operation with the minimum delay possible.

I turned to Jim and said, “Do you not find that the ward sisters (senior nurses) are generally much more helpful that the staff nurses (junior nurses)?”

“Yeah, I think there’s something in that. I think that the senior nurses see more easily that you’re trying to sort stuff out for the patients. If you’re being polite and ask reasonable stuff, then they do their best to try and help you out. I think that the more junior nurses have a tendency to lump all doctors together. If they’ve had a bad experience in the past, they get the “all doctors are arseholes” syndrome and it’s really difficult to get them to do anything at all.”

Reasons I don't miss Gen Med #2 - Calluses

As you can imagine, being a junior doctor in the modern NHS I spent a hell of a lot of my working time on “documentation” AKA paperwork. Writing in the patient’s notes, copying out drug charts, writing the request forms for referrals, writing out the discharge summaries for patients to take back to their GPs, writing requests for consultations, the list goes on and on…

Unsurprisingly, this all took its toll on my fingertips and over the past few years I have developed impressive calluses on the first three digits of my right hand.

In contrast, in anaesthetics, I spend much more of my time doing hands-on stuff with my patients and much less of my time on paperwork. As a result, four months after leaving General Medicine, my calluses are slowly shrinking.

Reasons I don't miss Gen Med #1 - The Ward Round Octopus

Before starting deciding to change my career path and become a trainee anaesthetist, I used to be a junior doctor working in General Medicine. This is the same job that Zach Braff’s character in Scrubs does, but I have to say I’m less inclined to have surreal lapses of reality.

I think whenever you decide to change an aspect of your life, you always wonder whether or not the decision is the right one. It’s now been several months since I made the switch and, looking back, I have no regrets.

Here’s the first of the reasons why I don’t miss general medicine.

The ward-round octopus



Ward round days were when the consultant in charge of the overall care of the patients on the ward would go round and see each patient, catch up with what we juniors have been doing and make decisions about their future care.

As a junior, it was my job to know what was going on, and to have all the relevant information to hand that allows decisions to be made. It was also my job to document conversations between the consultant and the patient in the medical notes and write down what the management plan is.

On a practical level, this was often a bit of a headache, especially because I was often the only junior on the ward round. It meant that I had to find the patient’s observation chart and make a note of their most recent blood pressure etc…, get the blood results folder (that I had previously prepared) and open it at the right page to see their most recent lab results, get the patient’s medical notes and find where to write the day’s entry (often not as easy as it sounds), all the while I’d be listening to the conversation between the patient and the consultant and writing down the relevant points as legibly as possible, whilst being ready to interject with any relevant scan/histology results and I’d also be trying to write down any tasks that needed doing over the next day or so… and I’d have to do this ALL AT THE SAME TIME.

Seriously, even with judicious use of all available flat surfaces (the notes trolley/bedside cabinet/patient’s bed/patient’s footstool), I felt like I needed an extra couple of limbs just so I could relay all the available information and write everything down so things didn’t get forgotten about.

This process would have to be repeated for every patient on the ward so I had to be quick with my octopus arms because after deciding on his plan, the consultant would move onto the next patient whether I was ready or not.

Winter Food

Piping hot roast ham cooked with honey and English mustard. Served with Scottish Maris Piper potatoes roasted in goose fat with carrots and broccoli.

This is followed by freshly baked apple & blueberry pie serves with lashings of double cream…

Eating this whilst all snug and warm while the rain beats down and the wind howls outside my windows, I realise…

I love winter food.

Saturday Night

I had last weekend off and I decided to go out and party hard because I hadn’t done that for a fair while. I spent Saturday night and the early hours of Sunday morning in various pubs and bars around the city with friends and had a really good time.

It’s around 03:30 and it’s time to go home. Me and my mates are in the taxi queue and it’s bloody freezing. All of us who are waiting are shivering, jumping up and down or huddling with friends to try and keep warm. The usual late-night banter is going on there’s the usual last-gasp efforts to try and pull and take someone home that evening.

Behind me in the queue is a rather attractive tall, young lady with her friend and behind them are a group of three guys. One of the men suddenly says to the tall girl.

“Oh my God! Look at your foot!”

The young lady has a small cut on the top of her foot that has bled. She’s wearing strappy high-heels so you can clearly see rivulets of dried blood across the top and down the sides of her right foot. The lady herself is pretty oblivious to it, like the rest of us, she’s more concerned with keeping the hypothermia at bay.

“You’re BLEEDING!” he continues.

She looks at him impassively, “Yeah, I know”

“You should go to hospital!” the man urges

A little alarm bell goes of in my head and I decide to cut in. “No, she doesn’t,” I say.

The man fixes me with a look. “Yes she does! Look at her foot, man.” He looks at her foot again, eyes nearly bulging out of their sockets. “You should go o A&E, you might bleed to death!”

“Look,” I say. “You don’t need to go to A&E, you just need to go home, wash your foot and put a plaster on it.”

I think that a little common sense can often go a long way.

Bleep etiquette

A friend showed me this Facebook Group, it made me smile:

"If you are a junior doctor, you now belong to the only profession in the developed world where you can be REQUIRED by contract to work a basic 91 hours in a week 'on-call'. When you work nights over Christmas and New Years you will be the lowest paid person in the whole hospital per hour (roughly minimum wage).

This group is for everyone who has been on call, on ward cover, or carrying a bleep of any kind. At medical school you longed for the day when you could carry one, and be a REAL doctor, didn't you?! Now you think of a few places you would like to shove the irritating, noisy, crappy bleeping thing...

We all love nurses, because they do the jobs we hate, and look out for us when we are just learning. They also gave the correct dose of drugs when you accidentally wrote milligrams instead of micrograms on your first day. We need them. But...

...there are a few points of etiquette that are unwritten, unspoken, but you just wish every nurse read, understood and inwardly digested:

1. Bleeping is not a spinal reflex. Please take a few seconds to breathe, think and organise your thoughts, and stop flapping about. Half the time you may realise you didn't even need to pick up the phone.

2. Mention what ward you are on. I don't have the whole hospital directory of numbers memorised. This is called the 'bingo-bleep'.

3. If you bleep someone, please wait by the phone. How can there be no-one picking up the phone at your end when I ring back?! This is called the 'bleep-and-run' and is exceptionally irritating.

4. Have the notes, obs chart and drug chart in front of you. Chances are I need to know what the obs were without waiting for you to run over to the bed and look, then run back over to the trolley to get the notes when I ask the next question. This is called the 'relay-bleep' and is probably not fun for you.

5. Please mention the name, age, and working diagnosis of the patient. The following is not acceptable: "Hello doctor, please see patient in 4, 6, she has chest pain". That is 'bleep-spam'

6. All patients with chest pain need an ECG. Don't bleep me until one is being done or there in front of you.

7. If I'm in theatre (surgery), leave a clear message. The following is not acceptable: "Can you come to the ward afterwards, there are a few things to do". This also counts as 'bleep-spam'

8. Once in a while I will not respond to my bleep. This is because I am jumping on top of someone's chest trying to save their life. I am NOT 'on break'. Doctors don't have these.

9. Please check with the other nurses that you aren't asking the same question as them. I really hate being bleeped from the same ward from two phones and two nurses for same patient. This is called the 'déjà-bleep' and is distinctly un-fun

10. You spend twenty times as much time with each patient than we do. We appreciate your opinion and pertinent information. The following is not acceptable: "Well you're the doctor, you should know". Well actually I'm on call and have never met this patient who has spent 5 weeks with you.

11. Please be cheery on the phone and perhaps even flirt a little. I've just spent 12 hours running around the hospital doing mundane tasks, talking to angry relatives, putting my finger up bums, taking blood and ordering xrays. You will get your way far easier by making me smile.

12. When I answer the bleep please don't say 'Oops, sorry I had a question but not any more". This is called the 'fart-bleep' and gets on my nerves (See also point 1).

13. Please don't ask me to see virtually every patient on your ward. That's called a ward round.

14. If you do cannulae on the ward regularly you will be my favourite nurse and I will do anything you say.

15. If I answer my bleep and the line is engaged because you are bleeping me from that phone again, I may well explode. This is called the 'torpedo-bleep' because of its incessant battle with my morale. Three hits and the boat may sink.

16. If a patient has died, he/she no longer cares how long it takes me to get to the ward. That's a medical fact. Chances are I can do a few other jobs on my way there. If you bleep me again for this patient it better be because they have miraculously come back to life. This is called the 'Lazarus-bleep'

17. The 'MEWS / EWS / EWSS / PARS' score is a trigger for you to call me and is useless after that. I don't give a crap what the score is. Tell me WHY the patient has scored it (e.g. respiratory rate? BP? heart rate?).

18. Please don't start a sentence "Just to let you know..." or "Just so you know..." I hear this 50 times per shift. This is called the 'zombie-bleep' and you have just inadvertently disengaged my brain.

19. Please don't make the person who picks up the phone have find to you from the other end of the ward. This is called the 'bleep-and-hide' (See also point 3).

20. Don't have someone else (e.g. a student) bleep for you. It's cruel to them, and they are not your secretary. This is called the 'kamikaze-bleep' (see also points 4, 5 and 19)

21. Dosing a patient's warfarin (whom you have never met and don't know their history) at 4am is horrible, tedious, legally dubious and just plain bad for the patient. Please slap the day team round their faces when they arrive the next morning and don't let it happen again.

22. Sit down! You may be surprised with how much this helps points 1, 2, 3, 4, 5, 9, 11, and 19

23a. If you happen to have a spare moment, eavesdrop when a doctor bleeps another doctor. The majority of the time you will see how it should be done.

23b. Sometimes point 23a doesn't work because the doctor is a week old and still learning the 'etiquette'. He/she will learn very quickly as their senior on the other end shouts them down!

24. When a patient is in an ACUTE confusional state, please do not repeatedly ask me for, or demand sedation. This is not the year 1912. I might give sedation AFTER ruling out an infection, over-medication, drug withdrawal, metabolic cause, trauma, neurological, hypoxic, endocrine, and vascular causes, and AFTER using every other method of calming down the patient.

25. Read the latest entry/entries in the medical notes. Your question may be answered already (see also points 1, 4, 12, 13)"

Keep Still!

“Why can’t you KEEP STILL? What’s the matter with you?”

I am 8 years old and am on the top deck of the bus with my mother. My young mind doesn’t really comprehend why my Mum is so angry, after all the bus seat was a bit springy and it seemed like good fun to bounce up and down on it like a trampoline. However, I’d learned not to mess around when she used that tone of voice and I considered myself told off.

------------------------------------------------------------------------------

“What’s the matter with you?”

“Huh?” I reply, bleary eyed and only just coming back to consciousness. The time is about 4am and I’m a second year medical student. I’m in the bed on my girlfriend at the time, but I can tell that she’s really pissed off and (not for the first time) I have no idea why.

“All you do is fidget, fidget, fidget all night bloody long! You keep kicking me and nicking all the fucking duvet! I never get a decent night’s sleep when you’re here. Why can’t you just KEEP STILL?!?”

Though I was only semi-conscious, I’d learned not to mess around when she used that tone of voice and I considered myself told off.

-----------------------------------------------------------------

I was with my consultant in the anaesthetic room today, and we’d successfully put our patient, Mr Elwood, to sleep. She turns to me and says “Have you seen any femoral nerve blocks being done?”

“Yes,” I reply “but I’ve never done one myself.”

“Well, now’s your chance. Tell me, how would you go about doing it?”

“I’d get a nerve stimulator and an insulated needle, then I’d draw up 30ml of 0.25% Bupivicaine and flush the needle through. I’d sterilise the area and I’d feel for the femoral artery. I’m go 2cm lateral and 2cm caudal to the pulse and push the needle through the skin. I’m looking for twitching of the quadriceps at the patella and if the twitches are present between 0.3 and 0.7 mA, then I’m in the right spot and can inject the local anaesthetic.”

“Very good, go for it then.”

I’ve got the needle in the top of my patient’s leg but I’m getting twitching of the adductor muscles, not the quadriceps. I angle the needle to the right a little and his kneecap starts twitching.

Good.

The consultant turns the amplitude down to 0.3 and the twitches cease.

“That’s perfect,” she says. “You know the tip of the needle is in exactly the right spot. Now, all you have to do is KEEP STILL while I inject the Marcain.”

I take a breath out and hold it. I manage to keep myself, my hands and the needle perfectly still while the consultant inject the anaesthetic.

Three hours later, on the orthopaedic ward:

“Hello there, Mr Elwood.”
“Oh, hello doctor.”
“How are you feeling?”
“Not too bad, I’m a bit tired like, but I’m alright really.”
“Do you have any pain?”
“No, not really”
“How’s the knee feeling?”
“It’s fine, it feels a bit numb, like you said it would, but it’s not sore or anything”
(This means my femoral nerve block is working perfectly.)
“Fantastic, well I’ll leave you alone to have a rest. I reckon you’ll need it because the physios will be after you tomorrow. I wish you all the best, sir.”
“Thank you very much doctor.”

And I went home feeling very happy. I wonder if my mother and my ex-girlfriend would be proud of me if I told them how I’d finally learned to KEEP STILL…

Going green?

I drive to work every day. I do what’s known as a “reverse commute” in that I live in the city but travel to work in one of the surrounding towns where the hospital is. This means that I miss the bulk of the rush-hour traffic because I’m travelling in the opposite direction, but, despite this, driving to work, is still a slow process that tests my patience on a twice-daily basis.

Environmetal groups seem to have the media in their pocket these days. You can’t open a newspaper or turn on the T.V. without being lambasted for putting your keys in the ignition. Our prime minister was at it yet again today. This ongoing guilt-tripping, coupled with the forever rising cost of petrol, made me decide to attempt to get to work without the car today and it was actually quite an interesting experience.

To be fair, for me, my car is a choice, not a necessity. I have a train station literally at the end and trains that take me the 15 miles to New Town run every 10 minutes at peak times. At the other end, the buses that go to the hospital are every 10 minutes as well. I don’t even need to look at the timetable!

So here’s my thoughts on going green and ditching the car for a day:

Journey Time
The first thing to note is that the door-to-door journey time is 15-20 minutes longer if I go by train. This may not seem a lot initially, but it’s the difference between leaving my house at 07:00 and 07:15. I’m not a morning person at the best of times and losing that quarter of an hour first thing puts bed and breakfast in direct conflict with each other.

Result: Car Wins

Cost
The council here do a quite nifty thing where you can by a regional travelcard that lets you travel around all day. This has the dual benefit of both being cheaper and not having to faff around trying to find loose change to give the bus driver at the other end. The travelcard cost me £4.50, which is about 50p more than the petrol costs of driving to work and back. I suppose, if I were to give up my car completely, the train would be relatively a lot cheaper because I’d save an awful lot of money on road tax, insurance and maintenance: but I’m not going to give up my little car just yet.

Result: Draw

Entertainment
I don’t know if any of you listen to radio first thing in the morning. If you do, you’ll agree that it’s shit. If I try tuning into Radio 1, my journey will consist of listening to Chris bloody Moyles laughing at the same unfunny joke for 40 minutes until I turn it off again. The CDs in my changer get boring after a while, so I’m spending more and more journeys in silence. On the train, the story is different. My mp3 player holds literally thousands of songs, so I can listen to whatever the hell I like. It’s much more enjoyable. It’s also got a radio on it, so in the unlikely event of me missing Moyley’s dulcet northern tones, I can tune in if I want to.

Result: Train wins

Stress
I suppose this is obvious but it’s worth stating that taking the train means I DON’T HAVE TO DRIVE. I’m not one of these people who finds driving for the sake of driving an enjoyable or worthwhile thing to do. Driving in the rush hour(s) is fun for nobody. Catching the train meant that I didn’t have to worry about being cut up by angry businessmen or being tailgated by some tool in a white Ford Transit or literally being crushed to death because someone driving an articulated lorry didn’t see me or missing my junction because someone won’t let me change lanes or being involved in one of the accidents I see on the motorway every three or four days… I could go on. The effect was that I arrived at work much more relaxed and in a better frame of mind to start the day.

Result: Train wins

Going outside
Taking the train means that I have to do more walking: from my house to the train station, from the train stop to the bus stop, from the bus stop to the hospital. The longest of these walks is only about 100m or so and I actually think they are a good thing. I tend to go from my house to my car to work to my car to my house and never really venture outside. At this time of the year, it’s dark when I leave home and dark when I return and if I’m not careful I end up just sort of becoming a creature that never sees the daylight or the outside. And that can’t be a good thing. Admittedly, when it’s freezing and raining like this morning, it’s not much fun. I’m not sure if I really want to start every day with a face-to-face confrontation with the British weather.

Result: Draw.

Learning
Not having to drive means that I can read. I really enjoy reading and feel I don’t do it as often as I would like. As I’m still very new to anaesthetics, I’m having to do a lot of studying at the moment. Using public transport means I can study on the train, it effectively gives me an extra hour every day to read up on stuff – if you were on the train at 07:30 today sitting next to a guy reading about isoflurane – that was me! If I’m not is a studying mood, I can just read a novel or newspaper instead. I think if I use the train everyday, I’ll end up being cleverer and more knowledgeable.

Result: Train wins

Comfort
As I said before, I do the “reverse commute.” This means that I had no problem at all getting a seat on the train or the bus today. The times I travel avoid annoying schoolchildren and it’s far too early for the chavs to be out of bed, so the journey was actually very pleasant.

Result: Draw

Final Result: Car 1 Train 3

All in all, I was pleasantly surprised by my public transport experience. I feel that if I take the train every day, my life will be “richer” in terms of mood, stress and learning. On the other hand, the extra 15 mins in bed that the car gives me is really important to a late-riser like me.

Overall though, I had such a good experience today that I’m definitely a convert to public transport. I can see myself going by train almost every day except supermarket shopping day.

I think anyone reading this should consider making the switch too.

- Michael

A request to all surgeons

If you’re at a crucial stage of the operation and are about to do something like slice through a kidney, clamp a major blood vessel, pull on the uterus etc… will you please let the anaesthetist know. You guys are pretty good at warning us when you are going to start, but after that, there's usually a whole load of silence and not much communication from you.

Remember, we can’t see what you are doing from where we are and a little warning about things makes our job so much easier.

Thanks

- Michael

Life-long learning #2

After the shenanigans of the weekend, it was back to work as normal today. This morning, I was giving an anaesthetic under the supervision of one of the consultants. I had just given my patient the injection that sends him off to sleep and was using the bag and mask to breathe for him.

One of the side-effects of the anaesthetic our patients is that they can rapidly drop the patient’s blood pressure. (For the medics among you, they cause a decrease in myocardial contractility whilst simultaneously causing profound vasodilation). This means that we always check the blood pressure and make sure it is stable before we allow the surgeons to start operating.

I press the button to start the blood pressure check, but the screen just reads:

Error: Cuff Leak.

The blood pressure cuff isn’t working and our ODP goes off to get a new one. The consultant turns to me and says, “What are you going to do now?” Referring to the fact that the machine was unable to ascertain if the patient’s blood pressure had fallen to dabgerously low levels.

“I’ll feel his pulse,” I say
“Which one?”
“The carotid” I feel the man’s carotid pulse. “He’s got one.”
“And this tells you the blood pressure is at least how much?”
“I don’t really know the exact figures”
“60 systolic. What are you going to do next?”
“Feel his radial pulse.”
“Good. Does he have one?”
“Yes, but it’s not very strong”
“If he’s got a radial, how high do you think his blood pressure is?
“80?”
“Yes, that’s right. You said it’s not very strong, so this man’s blood pressure will be just over 80 systolic.”

Our ODP has now returned with a new blood pressure cuff and we get a reading from the machine:

Blood pressure: 84/51

I was super-impressed.

You learn something new every day.

- Michael.

The Proposition

“Do you come to mine tonight?” Her breath was warm and her words slurred slightly as she whispered into my ear, “We could have lots of sex, if you want to.”

This wasn’t the first time I’ve ever been propositioned, but what really took be aback this time was that it seemed to come totally out of the blue. I was standing in a circle of a dozen or so nurses who had now stopped their conversations and were all looking at me…

Let me rewind a bit and tell you about how I managed to end up in this situation.

A couple of weeks ago, the intensive care nurses decided they were going to go for a night out. I spoke to David, the other novice anaesthetist, about whether or not we should go along for this night out with the nurses. David furrowed his brow and said “Hmmmm… maybe.” Going out on the town with a big group of nurses is invariably drunken and raucous and can be a hell of a lot of fun. One of my good friends once said to me, “you never see as much flesh on a night out as you do on a night out with the nurses.”

Quite.

David is a fellow MTAS refugee. That debacle means he is now separated from the woman he loves by a few hundred miles and, understandably, they try to spend every free weekend together. David told me he was bailing out on me and goes to visit his missus. I was actually quite disappointed because I was quite up for going out, but didn’t really want to be the only man on the girliest of girl’s nights out.

So, I’m sitting in my apartment, chowing down on a curry and watching No Angels on DVD (great show they should so bring it back) when my phone rings. It’s Asif, one of the anaesthetic registrars.

“Are you going out with the nurses tonight?”
“I was thinking about it but David’s seeing his girlfriend and I didn’t want it to be just me and the nurses. Why – are you going?”
“Yeah, I’d like to – do you fancy coming along?”
“I may as well, I’m not doing anything else tonight apart from watching TV”

We get to the pub/bar and the party is already in full swing. It’s really different seeing people you work with “out of context.” Some of the nurses I didn’t even recognise in their normal clothes. It was good though, the loud ones were still just as loud in the pub and the quiet ones were still quiet.

I really enjoyed chatting with the nurses and their husbands/boyfriends about stuff over a beer or eight. It was surprisingly civilised until Anna, one of the younger ones, got her camera out.

That was it. There was cleavage everywhere and it was all getting more and more risqué. A group of the younger nurses wanted to hit the club for a boogie and by this stage, I was well warmed up. Unfortunately, I couldn’t join them because Asif wanted to leave and he was giving me a lift home.

We start saying our goodbyes to everyone and we get round to the table where one of the nurses, Debbie, was chatting to some of her friends that I didn’t know.

“We’re heading off home now, Debbie. Enjoy the rest of your night.”

Debbie smiles at me, stands up, wraps one of her legs around me, plants a kiss on my lips and says, “Do you come to mine tonight? We could have lots of sex, if you want to.”

I’m sure this is the sort of stuff that teenage wet dreams are made of, a slightly older woman making a brazen, upfront offer of sex. The thing is, I don’t really fancy Debbie that much and, whilst I get on ok with her at work, I don’t know her that well either.

I weighed up her proposition in my mind. Sex is almost always great fun. Doing in with someone new is exciting. On the other hand, I didn’t particularly fancy her, and I think my “sex for the sake of it” days are behind me now – there are too many complications, especially in a situation like this.

I turn down Debbie’s offer. I can’t remember exactly what I said (that’ll be the Stella!) but I think I was quite gracious and gentlemanly about it.

It’s funny to think that I ended the evening being driven home by a large hairy, Asian man. I’m pretty sure if I was in the same situation five years ago, the end of the evening would have been very different indeed!

- Michael

The Streets

“What do you do to cope with stress?”

This is a question I’ve been asked at just about every interview I’ve ever been to. It’s quite a fair question, because I reckon that a being a junior doctor is one of the most stressful jobs you could do. I’d say I’m a pretty chilled person most of the time. I’m very mentally tough but I’m very laid-back as well. It’s rare that events get on top of me or get me down, but there have been times when things have happened that have brought me to tears. I’ve had several sleepless nights when I’ve replayed events in my head again and again in an eternally repeating cycle like some sort of sick cinema viewing.

There have been times when I’ve felt all alone and times when I’ve just asked myself “Is it worth it? Is the job worth feeling this bad for? Should I just pack it in and do something else?” In short, there have been loads of times when I’ve felt stressed.

The Beatles once sang “I get by with a little help from my friends” and I’m lucky enough to have fantastic family and friends to help me through the dark times.

One of the other things I do when I feel things are getting on top of me is pay a visit to the streets. I pull out my trainers from under my bed, pull on an old t-shirt and tracksuit bottoms, set my iPod to shuffle and go for a run. I love it.

I love that there’s just me, the beat and the streets; and for the time I’m on the streets, nothing else really matters. The streets have been there since before I was born and will be there after I die. The streets won’t care if I don’t shave before I run. The streets won’t gossip about me and won’t assume that because they can’t see me, I must be in the pub or playing golf. The streets won’t attempt to undermine me because I took a different route to my destination. The streets won’t hassle me about protocols or breeches or bed-crises and will just let me get on with running. The streets don’t expect me to run on all of them at the same time, in fact they expect me to visit them one by one. The streets are always there if I want them, no matter how long it’s been since my last visit.

If I stumble and fall on the streets, it’s only me that gets hurt.

- Michael

What do anaesthetists actually do?

I'd like to apologise to all you who emailed me when I was offline and I couldn't reply.

I was looking through my inbox and found this little gem that Mousie pointed out to me.

So funny, so true...

Cocky young doctor

Sometimes you meet people and they just get your back up.

Operating theatres are staffed by the anaesthetists, surgeons and ODAs (operating department assistants). The job of the ODA is to make sure the theatre runs smoothly. To check the right patient has some for the right procedure, to keep the theatre tidy and to pass things to (assist) the anaesthetists and surgeons.

I was working in a new operating theatre today and, when I entered the anaesthetic room, after seeing my patients on the ward, I introduced myself to the Susan, the ODA and Marcus, her student.

Sarah, the first patient, comes in and Susan and Marcus complete their checks and then I set about the business of actually giving Sarah the anaesthetic. I start putting the drip in back of the patient’s hand and Susan says,

“Why are you putting it there? Why don’t you put it in her wrist? It’s better in the wrist.”

This annoys me. I may be young but I’ve probably sited close to a thousand drips so far in my career and I KNOW how to do it. I feel that she is trying to tell me how to do my job. I let it pass and the drip goes in to the patient’s hand first time.

Susan and Marcus had got the intubation stuff ready and I did my mental check so that I knew where everything was before I started. Oxygen? Yes. Suction? Yes Laryngoscope? Yes. Bougie? I couldn’t see it.

“Do we have a bougie?” I ask.
“It’s over here” Susan replies, pulling one out from behind the anaesthetic machine, “I’ve been in anaesthetics a lot longer than you, you know” she adds.

I wonder if she’s deliberately trying to wind me up. I know she’s been “in anaesthetics” a lot longer than me. She’s about 50 years old and was probably doing the job the day I was born, but I also know that I’m the anaesthetist and she’s my assistant. I have to look after this patient. I’m about to give her medications that will first send her into a coma and then paralyse her so she can’t move or even breathe for herself. I have a duty to make sure I can keep her alive and unharmed, so I NEED to know EXACTLY all the equipment I may potentially need is because I have only a few seconds to intubate my patient before she starts to suffer ill effects. When I spoke to Sarah on the ward, I made a promise to her that I’d look after her and the best way to look after her is to anticipate things that could go wrong and to nip them in the bud.

Once again I let Susan’s comment slide and I inject the anaesthetic drugs into Sarah’s vein. Marcus passes me the laryngoscope and I slide the blade into Sarah’s mouth.

“Don’t damage her teeth will you?” Susan pipes up

I can’t see what I’m looking for and I slide the blade further into Sarah’s throat.

“Watch out for her teeth!”

The blade is not near her teeth, so I ignore Susan and concentrate as the epiglottis pops into view.

I lift the blade to visualise the vocal cords.

“Careful with her teeth!”

The blade is still nowhere near Sarah’s teeth and Susan is really annoying me because I’m concentrating all I can and she is distracting me at a crucial moment.

“I’m nowhere near her teeth! You are NOT helping” I snap.

I push the endotracheal tube into Sarah’s trachea then connect the ventilator. We can now start the operation safely. I look up and Susan is giving me a look that could kill.
No doubt I’m now a “cocky young doctor” who “thinks he knows everything” and “doesn’t respect experienced staff members.”

Sigh.

Demystifying the ICU black hole

As a doctor working in general medicine, the intensive care unit (ICU) seemed to be a mystical place. When our patients became very, very sick, we would ask the ICU doctors for help and then they’d swan down onto the ward and point out all the things we hadn’t done. What usually happened next is that they’d then say that they didn’t want to take the patient onto the unit, offer a little advice and swan off again. However, very occasionally, they’d they WOULD take the patient and within minutes, the patient would be whisked off to the intensive care unit. They’d vanish off behind big, locked doors and we never knew what happened to them there. It was like a big black hole that the patients disappeared into. Sometimes, they re-emerged days later, sometimes they never came out.

The bible for junior doctors across the land is the Oxford Handbook of medicine. If you read the sections on treating critically ill people, regardless of the condition, it’ll say something like “do X then Y then Z and if that still doesn’t work, call ICU.” Rarely, do you get any more details and, as a result, I was always more than a little mystified about what went on behind those locked double doors. It’s been a real revelation working on the intensive care unit and seeing things from the other side.

To be honest with you, I was a little underwhelmed when I found out the truth. Aside from mechanical ventilation, nothing particularly special or profound happens in intensive care. Intensive care is based around meticulous attention to detail. It’s based around being focused on every aspect of your patient’s wellbeing. Closely monitoring ALL of their organ systems and intervening quickly and appropriately to try to correct anything that is drifting awry.

I’d say the single biggest difference between ICU and a normal medical or surgical ward is the nursing staff. I’m not saying that the nurses are better on ICU, it’s just that there are many more of them. We get one nurse for every patient. It’s great. It means you have so much more scope to do things. For example, we can confidently put a patient on an infusion of midazolam with the knowledge that they’ll be someone around to turn it off if the patient stops breathing.

It’s also made me realise that it’s often the simplest of things, done early, that make the biggest difference to critically unwell patients. Things like giving oxygen or fluids or adequate pain relief. I honestly believe that every doctor working in an acute specialty should spend some time working in intensive care at some point. Intensive care is based around simple things done well. Good medical care is based around simple things done well, and this is what I’ve seen again and again over the last few months.

I'm back

I’ve been having issues.

The reason I’ve not blogged for so long is not because I was bored of it or had nothing to say; it was because MTAS made me move to a different part of the country and, believe it or not, it’s taken until now to sort out an internet connection. Surely British Telecom must be the most inefficient, frustrating, incompetent, uncaring organisation in existence. Grrrr….

Anyway, I’m back now and in the couple of months I’ve been offline, I’ve found my feet somewhat as a novice anaesthetic trainee. I’ve spent most of my time working on the Intensive Care Unit and it’s really opened my eyes regarding what the human body can and cannot do.

Our patients are usually right on the brink of dying and they are constantly fighting with whatever little strength they have left to do the simplest of things – like breathing. I have to say that the intensive care unit runs really well and over the past few weeks its been a pleasure and a privilege to work as part of the team that works so hard to try and make our patients better. Sometimes we succeed, and sometimes we fail, but every day brings new challenges and I have to say that, three months after changing my career direction, I’m still really enjoying being a novice anaesthetist.

"MMC & MTAS 2007 – a post-mortem" or “Lies, bad advice and how I got my job”

Last week, Hospital Phoenix wrote about some nonsensical advice that was given to one of his friends at his trust induction. This got me thinking about MMC once more. There are many things that are horribly wrong about Modernising Medical Careers and the Medical Training Applications System but, as someone who actually had to negotiate this disaster, the single thing that I found most galling, most frustrating and most stressful about it was the utter lack of information about the scheme and how it was intended to run.

In spring 2006, when the changes to the medical training system started to change from vague chatter on the college websites to firm plans, I tried and tried to find out how certain aspects of my training and experience would fit into the new system and what I should be doing to get a job. It was all in vain. I lost count of the number of times that my questions were met with a shrugging “I don’t know.” In December 2006, I was getting more than a little stressed by it all and contacted, in rapid succession, – MMC, the royal college of physicians, the royal college of anaesthetists and PMETB about what I should do when the application process began. Nobody had any idea. Here are a few of the responses I got:

PMETB: “I don’t know, applications are nothing to do with us.”
MMC: “I don’t know, you should just apply to whatever you think and not be too picky about where you want to work.”
RCoA: “I don’t know, you don’t fit into any of our boxes do you – ask MMC”
MMC (the second time): “I don’t know – maybe you should do an FY2 year.”
RCP: “I don’t know, but you have your exam so I think you’ll be OK.”
RCoA: “If you do find an answer, could you come back and tell us because we’d be interested to know too.”

Do you feel my pain? Finding any sort of useful information was like drawing blood from a stone and the information I did manage to extract was either unhelpful or just plain wrong. The consultants at the hospital I where I was working at the time were less than useless and I took gossip about the changes among fellow junior doctors with a pinch of salt. I discounted rumours like “they are going to sacrifice a whole generation of SHOs to make the new system work” and “there are going to be thousands of unemployed junior doctors” and “families will be torn apart by this” as scaremongering by the hospital stress-heads. Surely they wouldn’t do that to us? I thought.

I was wrong. As you probably know, the actual reality was far worse.

Advice from consultants about getting a job through MTAS was appallingly bad. They just trotted out the same stuff that had helped under the old system and I don’t think they realised that the goalposts regarding job applications had fundamentally changed. This is part of the reason why it came as a surprise to many when high quality candidates weren’t even being short-listed in Round 1 (later renamed to Round 1a). At various times during the application process, various consultants told me things like; “It’s very important that you have your [post-graduate] exams, it’ll help you stand out” and “It’s always worthwhile contacting and visiting the department [of the job you’re applying for] before the interview” and “Make sure your CV looks good” etc… etc…
All this advice sounds reasonable, but was absolutely useless when it came to applying for jobs this year. I very much doubt I’m alone in being told these kind of things by my seniors but the facts are that if you paid attention to your bosses and actually followed advice like this, you’re highly likely to be unemployed right now.

The MMC themselves recognise that misinformation and a lack of useful information was one of its (many) major failings this year and, to be fair to my former bosses, they were probably as much in the dark about the changes as we were.

The thing that galls though is that, as the system fell apart and as it became increasingly apparent that you needed to do something different in order to get a job, the old advice still stuck.

I’ve commented before about how I feel let down by Liam Donaldson and the government for instigated and overseeing the MMC fuckup. I also feel let down by the senior doctors, the consultants, during the whole affair. Generally, I felt the majority of them just didn’t care at all, the advice given by them was often a load of bollocks and the way the BMA (led by consultants) behaved when they sided with the government against us juniors was truly disgusting.

I was interviewed four times in Round 1a, including once for the position I was working in at the time (effectively being re-interviewed for the job I was already doing), and didn’t get any job offers.

Round 2 was a total fucking debacle. Jobs were (or weren’t) advertised ad hoc, in random, hard-to find places for stupidly short lengths of time. Some deaneries made life as difficult as possible for applicants and, in places, what MMC said about how things were meant to run bore little or no resemblance to what was actually happening.

Here are some examples of skulduggery by the deaneries in round 2, all of which are DIRECTLY contrary to what was published on the MMC website. The London Deanery advertised and then closed its Round 2 anaesthetics jobs BEFORE round 1 had even finished and then appointed only current London-based trainees to the positions. The Round 2 Core Medical Training jobs for the South Yorkshire South Humber Deanery were PHYSICALLY IMPOSSIBLE to apply for from outside the region because the application form was only made available on the day of the deadline and they insisted on having 10 paper copies. The Leicester, Northampton and Rutland Deanery didn’t even bother publish a deadline for its Round 2 anaesthetics jobs.

These are just examples that directly affected me and I’m sure there are many, many more examples across the nation. By the way, if any of you do know of any more, I’d be interested in hearing about them.

Anyway, after many hours spent filling out endless application forms, I got myself short-listed in Round 2. I was successful at interview and was given one of the much-sort-after ST run-through positions. I was very lucky indeed.

I was on the phone to my old registrar the other day and, apparently, the new junior doctors on the firm are less qualified and less experienced than we were. This begs the question, “how come they got the job and I didn’t?”

The answer, I think, goes back to what I was talking about at the start of this post – bad advice. If I could go back to December 2006 and give myself one piece of advice it would be to sort out my portfolio and this is the advice that I give to anyone still negotiating the system.

I thought I interviewed very well in Round 1 and was actually quietly confident about getting a job. I was wrong. The computer said “No.” I thought I interviewed very well in Round 2 and was quietly confident about getting the job. I was right, I dodged the dole office with about a fortnight to spare and am now really enjoying my work (though I’m lamenting the fact that I’ve had to move hundreds of miles from my friends and family).

The difference between Dr Michael Anderson in Round 1 and Dr Michael Anderson in Round 2 was that, by the time Round 2 came, I had buffed my portfolio to the max.

I’d gone round and asked my medical students to sign something to say I’d taught them how cannulate and read ECGs, I asked the senior sister to write a letter saying I was nice to patients and staff, I’d got a consultant to write a letter saying that I can ably cover CCU and HDU, the list goes on. I have to say at this point that this wasn’t EXTRA stuff I was doing after failing in Round 1. I was doing all this stuff when I had my Round 1 interviews - it just wasn’t in my portfolio at that time.

Whether you think that I was incredibly shrewd and learned from Round 1 and “sold myself in the best possible light” or you think I “shamelessly played a flawed system to get a job” will depend on your standpoint.

The fact is that in MTAS 2007, this sort of portfolio stuff is considered more important than previous experience, publications, post-grad degrees etc… and this is a fundamental change that my seniors and the majority of my junior doctor colleagues just failed to realise. Whether or not this is the way it SHOULD be is a matter for another debate. Personally, I’m praying that MTAS 2008 will be drastically different to MTAS 2007, but I have my doubts.

You see, as we enter September 2007 and contemplate the applications for next year, I don’t see that a great deal has changed. As was the case in September 2006, it seems nobody has a clue about how the system is going to run next year and everyone is still “waiting to find out.” I’m willing to bet that a junior doctor seeking advice about how to apply next year will find getting any useful information virtually impossible – just like I did last year. To quote a great woman “It’s all a bit of history repeating.”

I hope I’m wrong. Time will tell.

Choose life?

From medical school to retirement, doctors are told and reminded to respect patient’s autonomy. This means that we must respect the decisions they make about their own health, even if that decision seems nonsensical to us. This theme comes up again and again throughout our careers. Our attitudes to patient’s autonomy is tested in exams and vivas, the lawyers remind us about it during the Trust inductions, it’s a common theme in our job interviews, it comes up at conferences, in the media and, most importantly in our daily interactions with patients.

The vast majority of the time, patient autonomy is not a conflict issue. This is because the doctor and the patient are working together, in harmony, to try and achieve a common goal. Patients come to us because they want to get better, we doctors suggest something that we think will make them better and patients usually agree to it and then they usually get better. Their autonomy is driving them in the same direction as our medical advice.

Sometimes, the patient will have a different agenda to the doctor and sometimes, their agendas and beliefs drive them to make decisions that fly in the face of our advice. Sometimes, we can understand where they are coming from and sometimes we can’t. Nevertheless, respecting patient autonomy is one of the core duties of being a doctor.

Anil, one of the new junior medical doctors and fellow MTAS refugee, was telling me about Helen, a 43 year old woman whom he had seen on the Medical Assessment Unit the day before.

Helen came to hospital because she was very unwell. History and clinical examination showed that she was bleeding internally, possibly from an ulcer, and had lost a lot of blood. (For you medics reading, her Hb was 4.9 g/dl). She was critically ill and urgently needed a blood transfusion to keep her alive until the bleeding can be stopped either by endoscopy or by surgery.

The thing is, Helen is a Jehovah’s witness and Jehovah’s witnesses do not accept blood transfusions. Moreover, Helen is a recent convert to the religion and, as such, is much more hard-line about sticking to her beliefs, even in extreme situations.

Those adverts about giving blood really do speak the truth, you know. Blood transfusions do literally save lives. Helen is highly likely to die without a blood transfusion, leaving behind a grieving family, but Helen flatly refused to have one.

This is exactly the scenario that is frequently used to illustrate autonomy in medical school, in junior doctor’s teaching sessions etc… etc… so it’s interesting to hear about this scenario actually unfolding in real life.

The thing about autonomy is that if a patient is lucid and has capacity to make their own decisions, then we have to respect the decisions that they make about their own lives. As doctors, it’s our job to make the patient fully aware of the likely outcome of their decision and to treat them the best we can whilst respecting their beliefs, no matter how bizarre they may seem to us. It is wrong to force our will onto our patients, it is wrong to lie to our patients about what might happen to them.

Anil told Helen that without the blood transfusion, she is likely to die, aged 43. Helen said she understood this but would rather die than have the transfusion. This is her decision.

When Anil finished his shift, Helen was still alive, but was teetering on a knife-edge. She was having intravenous fluids and the medical team were preparing to take her down for an endoscopy to hopefully stop the bleeding. I just hope that the prayers of Helen and her family are answered and she makes it through.

Stronger

Kanye West, the sample-happy multimillionaire rapper, has shot to the top of the pop charts with his new single, Stronger.

With his hand gripping the mike and a deep, earnest look on his face, he croons “Na na na…That that don’t kill me will only make me stronger...”

Now, I respect Kanye’s ability to turn other people’s tunes in platinum selling bundles of 3 minute joy that make him a fortune, but it’s obvious to me that he’s never spent any significant amount of time in a hospital.

I can think of loads of things that don’t kill you but certainly DO NOT make you stronger. Off the top of my head, I can think of:

Herpes
Strokes
Heart Attacks
Schizophrenia
Amputations

Can you think of any more?

The MTAS refugees... Our Story #1

Sumitra is one of the new registrars in the New Town anaesthetics department. Like me, Sumitra is an MTAS refugee. Before the government decided that was perfectly reasonable to force thousands of junior doctors to move hundreds of miles away from their families and friends, Sumitra lived with her husband and four children in a town about four hour’s drive from New Town.

Sumitra is quite a bit older than I am. She decided to take time out from working to bring up her children and she also had a change of speciality along the way as well. Her husband has a career that means he can’t easily move and the eldest of her children is beginning the run up to GCSEs. Understandably, Sumitra isn’t really keen to relocate her whole family up toward New Town because of the disruption it’s going to cause. Added to this, there’s the fact that she doesn’t know this area at all. She doesn’t know which suburbs are nice to love in, or which are the decent schools etc… etc…

I’ve had several conversations with Sumitra about what she’s going to do and she just doesn’t know at the moment. What I do know is that having to move to a place four hours away from her family is going to put a huge strain on Sumitra’s relationship with her husband and her children. Hopefully, they’re a strong enough family to be able to work it out somehow.

A.B.C.

The junior doctors on the intensive care unit are a bit of a boy’s club. Just about all the SHOs and registrars are attractive young men, and most of us are single. I’m blogging about this because this is so unusual.

Hospitals are dominated by women. Fact.

The vast majority of the staff in any hospital are female. The nurses, the domestics, the caterers, the admin staff etc… tend to be almost exclusively female. Back in the day, the majority of young doctors were male but that is no longer the case. The gender ratio of new doctors is about 60:40 if favour of women and, going by the relative numbers entering medical school, the ratio is going to swing even further towards the “fairer sex” in the next few years.

This means that, as a young male in the hospital, I am a bit of a commodity and, when I was first starting out, it made things just that little bit easier for me. I could flirt with some nurses, whilst others would want to “mother” me. Some of the patients, especially the older ones, gave me more respect just because I am a man. I remember being on the ward round with my female consultant when I was a house officer and the patient (a lady in her 80s) asked the consultant to be quiet so she could “listen to what the doctor had to say” - and then looked at me.

It’s not all plain sailing and waving my Y-chromosome in the wind though, there are downsides as well. There are the endless conversations about sunbathing and shopping. (I’m still to fathom out the female obsession with shoes – two nurses and a female doctor once managed to have a conversation about heel height for 40 minutes straight – the mind boggles). Discussions about football end up all about the shapeliness of Frank Lampard’s legs or how Wayne Rooney is dead sexy because quote: “he looks like he’d leave you feeling raw afterwards”. And then there’s the expectations that I’ll act as a spokesman for my gender whenever one of the staff got played around or cheated on or dumped.

Overall though, as a junior doctor, the boys get an easier ride than the girls.

However, I’m finding it refreshing working with mainly other men. Men are funnier than women so there’s more banter on the ward. It’s also nice to have conversations at work about blokey things and not have to save it for the pub.

Call it sexist if you want to, but I think the Anaesthetics Boy’s Club (ABC) is definitely a good thing.

We'll pick you up if you fall... always

Kevin is a man who had been involved in a high speed crash on the motorway and had arrived in New Town hospital fighting for his life. He’d broken both his arms, his jaw, his ankle and his breast bone. He’d had three large tubes inserted into his chest (one placed by yours truly) to drain away the blood that was collecting round his lungs, he had been unconscious on a ventilator for nearly a week and needed four separate operations on various bits of his body.

Kevin had come to us a broken man but, little by little, we’ve slowly put him back together again and Kevin is continuing to improve. It’s a heart-warming story of strength through adversity.

Whilst I was looking at the chart of the patient opposite, I heard Kevin talking to one of the student nurses. He said.

“The best health service in the world this is, the NHS. The way you people have treated me… I couldn’t ask for anything more. Even if I’d paid money, I wouldn’t have been treated like this. Thank you.”

Stuff like that makes you feel warm and fuzzy and really appreciated. Now, if only Kevin was a journalist…

One more joins the fray

I found the Lowly Worm's blog. It's great, you should read it too

MTAS refugees (Friday)

We who have had to up sticks and move hundreds of miles to our new jobs because of the government's fuckups are calling ourselves "The MTAS refugees."

In our department, about 60-70% of the new starters have been forced to move away from where they were previously against their will because of MTAS. From speaking to people in other specialties, it's clear that the majority of the junior doctors who had to negotiate MTAS and were successful have had to move significant distances to find work. I don't think the government could have actually been more disruptive if it actually planned to be

You already know my story, but next week, I'll post about some of the other MTAS refugees.

12 days of anaesthetics (Thursday)

Today is my twelfth day as an anaesthetic trainee, and I'm going to have a look back at what I've done so far...

On the twelfth day of anaesthesia, my duties gave to me:

12 Cannulations
11 L.M. Airways
10 Worried Parents
9 Intubations
8 Angry Surgeons
7 Patient Transfers
6 Gas Inductions
5 Vomitings
4 Bag & Masks
3 Spinal Blocks
2 Chest Drains

and a pair of medium scrubs…

My medical student is flirting with me… (Wednesday)

…and she’s really rather attractive. Her name is Lizzie and she’s currently doing her intensive care/anaesthetics placement.

I’m not one of those men who think that the every female with a pulse is secretly swooning when I walk past, but, as a reformed (wannabe) playboy, I think I have a pretty good idea of when a woman is signalling “I like you.”

It’s the touch that’s not quite necessary. It’s the gaze that lasts a moment longer than needed. It’s the laughter at things that I say that are only vaguely funny. It’s the turning up and coming to talk to me when there’s no need to really… Reading between the lines I’d definitely say Lizzie is flirting like a pro.

At first I wasn’t sure if she was just one of those flirty girls who are like that with everyone, but now I’m pretty sure she’s giving me “special attention”. Like I said before, she’s a very attractive young lady and I admit that I’ve been flirting back a little because, to be honest, I quite like it.

Throughout medical school and into my first year as a doctor, I was very anti work-related relationships. Looking back, I don’t even remember what my reasons were but I’d actively avoid dating/pulling/shagging other medical students, nurses or anyone who I worked with. From this point of view, I’ve mellowed a lot in the last couple of years and am not so dogmatic about it now.

This leads on to the obvious question of is anything going to happen between me and Lizzie?

One of my best friends told me: “Don’t even go there, Mike. Pulling a medical student is just wrong.”

But he’s been going out with the same woman for six and a half years now, so what would he know? You can talk about power and its (ab)uses but it’s not as if Lizzie is a schoolgirl and I’m her teacher is it? She’s 23 years old and I think that makes her a big girl and quite able to make her own mind up.

For now, I’m quite happy to sit back, let her make the moves and wait and see what happens…