Anatomy of a night shift

The tagline under the title of my blog says “Diary of a junior doctor.” I feel that, currently this is a bit of a misnomer because since I started, this blog at no point have I written a “diary” of what I actually get up to. I’m going to attempt to rectify this situation with four posts that detail what I, an anaesthetist in training, actually do with myself all day (and it’s a bit more than sitting reading the paper).

Anatomy of a night shift

19:45

It’s dark and it’s raining. I’m in my car driving towards the hospital to do another night shift. I’m actually feeling pretty good. Hands-free mobile technology has allowed me to spend much of my journey chatting to my girlfriend. I pull into the hospital car park and have enough time to grab a coffee, and get changed into my scrubs before the shift starts at 8. As the anaesthetic SHO on-call, my most important duty is to keep the Emergency Surgery (CEPOD) Theatre going so all the patients who need operating on that day have their operations. Sometimes, there’s an operation going on as I start my shift, sometimes there isn’t. I wonder what’s happening in theatre at the moment

20:00

There is indeed an operation going on. I walk into the operating theatre and say hello to Melanie, the anaesthetic SHO on-call for days. We exchange pleasantries about how her shift has been (frustratingly slow) and she tells me about the patient. Surgery has just started on a fit, healthy 4 year-old girl who had split her lip open and the Maxillo-Facial surgeons were just going to sew it up again. There were a couple of other people on the list for surgery tonight, one 12 year-old for an appendicectomy and one 71 year-old with a broken leg that needed fixing. I get a handover from Mel about the child on the table, take hold of the breathing circuit and Mel goes home.

The Max-Fax surgeons were true to their word, the operation doesn’t take long at all. When they finish, I turn of the anaesthetic vapours, turn up the oxygen and wake the little girl up.

20:20

I’m in the recovery area and I’m satisfied that the girl is awake, comfortable and breathing for herself. One of the theatre nurses comes up to me and asks, “Can we go and get the next patient now?”

“No,” I reply. “I haven’t seen this boy yet.”
“Can’t you just see him in the anaesthetic room?”
“No. I’ll see him on the ward.”

Personally, I think that people should be given the opportunity to speak to the anaesthetist before they come down to theatre. Also, my seeing the boy on the ward gives me to pick up any problems that the surgeons may have missed/ignored and potentially do something about them before the operation.

I trek across to the children’s ward and meet young Joe who is lying in bed with his mother beside him. Joe is actually quite sick. He’s had belly pain for two days now and he has a fever of 39.1˚C, his heart is racing and he’s very still and quiet, the way children get when they feel really rough. I do my pre-op assessment and then I tell Joe and his Mum what to expect when they come down to theatre. Joe has lots of questions about exactly how I’m going to keep him asleep and I spend a bit more time explaining how anaesthesia works and reassuring him a bit.

I let the paediatric nurse looking after Joe that someone will be up to collect him quite soon and then head back to theatres via the Intensive Care Unit. I find the anaesthetic specialist registrar (SpR) – my immediate senior. It’s VJ tonight. He already knows there’s a child booked for theatre. He asks me if I’m happy to carry on with the case alone. I tell him that I am and head off back to theatre.

21:10

Joe and his mother arrive in the anaesthetic room. I’ve got everything prepared and I set about getting Joe anaesthetised. He’s been sick earlier, so I plan to do a “crash induction” and intubate him. Crash inductions (or Rapid-Sequence Inductions) can be quite fraught with danger, especially in unwell patients and especially in youngsters. I’m aware that I’m all alone so I make doubly sure that everything is ready and everything I may need is to hand. It’s not a problem though. I safely get Joe anaesthetised and intubated and the nurse takes his Mum away to have a coffee.

The operation takes a while because the surgical reg is teaching the surgical SHO. About half an hour into surgery, my pager goes off.

“Could you attend A&E resus IMMEDIATELY please. Airway problem.
Could you attend A&E resus IMMEDIATELY please. Airway problem.
Could you attend A&E resus IMMEDIATELY please. Airway problem.”

There’s no way I’m leaving this anaesthetised, intubated, ventilated child to go to A&E resus so I ask one of the theatre assistants to phone switchboard and get them to page VJ, the night anaesthetic SpR on-call, as I am unable to attend.

22:45

The operation is all over. Joe had a nasty, perforated appendix but now it’s been removed he should start to get better. I waken him in recovery and he’s comfortable, if a little tired.

Emily, the ODP on nights asks me what I’m going to do about the last patient on the list – the man with the broken leg. I tell her that I’m going to check what’s going on in A&E and speak to VJ, and then I’ll get back to her.

22:50

A&E resus is empty. I figure that if it was an airway problem, then the patient may well be in the CT scanner so I walk round to radiology. I’m proven right. There’s a clutch of people in the observation room of the CT scanner. VJ has intubated and sedated the patient and a quick glance at the screen tells me that whoever the patient is, they have a significant amount of bleeding inside their skull. Bad news.

On the return journey to A&E resus, VJ fills me in with the story of what happened. Basically, the patient is a 25-year-old man found semi-conscious by his housemate when she got home from work. VJ had done a great job in stabilising the patient regarding blood pressure, sedation, monitoring, carbon-dioxide levels, oxygenation and ventilation etc… etc… There’s more to do though, and I give him a hand as the A&E doctors get on the phone to the neurosurgeons at TheBigTeachingHospitalDownTheMotorway.

The brain surgeons listen to the history, review the CT scan results and agree that this man needs emergency brain surgery tonight.

“I’m going on a journey, aren’t I?” I ask VJ
“Looks like it,” he replies. “Have you done inter-hospital transfers before?”
“No.”
“OK, well there’s a few things that you’ll need to be careful of…” says VJ, and then proceeds to give me a five-minute crash course on how I should transfer this patient.

I’m not actually all that concerned. The patient, Jimmy his name is, is pretty stable from a cardio-respiratory point of view. I just make sure that my monitors are working, I have the drugs I may need in my pocket and that all my equipment is present and in working order. I also make sure I take my coat, some money, my mobile phone and my sandwiches.

00:15

The ambulance crew are here and we load Jimmy into the back of the ambulance. Emily, the ODP, and I squeeze into the back and the two ambulance crew hop into the front, turn on the blue lights and off we go.

The journey itself is pretty uneventful. I have to play with Jimmy’s arterial line a few times to get it to keep working. I also notice that when we’re on a bumpy part of the road, the ECG monitor does a good impression of VF, which was initially quite disconcerting.

During the journey, I start to feel tired. I wish I’d had a coffee before we left, but Emily and I share my sandwiches and this helps keep us going.

When we arrive at TheBigTeachingHospitalDownTheMotorway, we go into A&E resus. Straight away, TheBigTeachingHospitalDownTheMotorway’s nursing and medical staff are surrounding us asking questions and organising various things. I give two handovers, initially to the A&E SpR and then to the consultant anaesthetist who has come to take the patient to theatre. I have to say, having so many people who I don’t know doing stuff all at the same time is really distracting. I have to really concentrate on ensuring that in the midst of the milieu, we are still breathing for Jimmy and looking after him. He goes to theatres pretty quickly though and Emily and I hop back into the back of the ambulance for the journey home.

02:40

We arrive back at my hospital. I really am feeling quite shattered at this point, so I go and get myself a coffee. I really do believe that after midnight, the NHS runs on caffeine. I go and find VJ and get my pager off him.

He’s on the High Dependency Unit (HDU) and we have a quick debrief about my journey to TheBigTeachingHospitalDownTheMotorway. Our chatter is cut short by the sound of his pager going off. It’s the medical registrar with a referral for us from A&E.

02:45

VJ and I arrive in A&E and get the full story from the med reg about his patient, Mr Singh. Basically it’s a middle aged man with very severe, community acquired pneumonia. We go and review the patient along with the results of the investigations the medics have done. VJ ummms and aaaahs for a bit about whether or not to accept the patient onto the HDU. Eventually he decides to accept him and he explains his rationale to me.

“Basically, Michael, this man is on the borderline. As he is right now, he would probably be alright on a normal ward – just. My concern about him is his oxygenation. His pO2 is only 15 despite breathing high flow oxygen via a rebreathe mask. If he gets any worse than he is at the moment, then we’d probably have to intubate and ventilate him and it’d take forever to get him off the ventilator. If we accept him now, give him some CPAP and lots of chest physiotherapy, we may help him turn the corner and avoid intubation.”

We discuss things with the med reg, add a few things to his management plan, call in the physiotherapists and ask the nurses to transfer him to HDU as soon as they can.

03:40

Mr Singh arrives onto HDU. The nurses do their admission and the physiotherapist does some chest physio with him with moderate success.

VJ finishes writing up the admission notes and then turns to me and says, “I might go and try and get my head down for a bit, are you alright to put in an arterial line by yourself?” I tell him that I am and he leaves the unit.

The nurses had kindly put together an arterial line, “A-line,” trolley for me and I go to Mr Singh’s bedside and explain what I’m about to do. The last three A-lines that I have done have all gone in like love’s lost dream, so I’m pretty confident I’ll be able to site one into Mr Singh. The one I did last week went in so easily that the attractive-married-but-still-very-flirty A&E nurse remarked, “Wow! Well done! You are really good at those!”

Unfortunately, my confidence is misplaced in this case. Maybe it’s because of his tachycardia, maybe it’s because it’s the middle of the night and I’m tired, but I find it a real struggle. I try once and get a flashback but the catheter refuses to advance. I try again and manage to kink the tube. I always use large amounts of local anaesthetic when doing these, so Mr Singh is not at all bothered by me poking around his radial artery with a big needle. I don’t seem to be able to feel a radial artery pulse at all on the other side so I try a third time on the same side. “One last try,” I tell myself but it’s no good. I get a flashback again but once again, I can’t get the catheter to advance. I’m getting really frustrated as I’ve been trying to get this sodding line in for nearly an hour now. I consider trying a different site- perhaps the brachial artery or the dorsalis pedis, but, on balance I decide to keep my promise and I give up.

I tidy away the A-line trolley, go to the phone and bleep VJ to come back and help me out. He comes back to the unit and uses the ultrasound machine (why didn’t I think of that?) to gently coax the A-line into Mr Singh’s radial artery. VJ is a great reg to be on with and he gives me a quick 101 in how to use the ultrasound machine and the best tricks for locating the ulnar, median and radial nerves in the forearm using ultrasound.

05:30

Our little teaching session is interrupted by one of the ICU nurses asking us to come and have a look at her patient because she’s rather concerned about him. The patient is question had had a long maxillo-facial operation and reconstruction for cancer. We were using a drug (metaraminol) to keep his blood pressure up, but, the same drug was causing his heart to beat worryingly slowly. Said nurse had turned off the metaraminol pump and asked us to come and review.
VJ had had a handover of all the patients in Intensive Care at the start of his shift and was pretty au fait with this gentleman’s problems. He turned the drug back on again and gave the nurse explicit advice about which drugs to give if his heart rate fell below 40 beats per minute. As we leave his bedside, it occurs to me that this big man with scars and staples across his face looks not too dissimilar to Frankenstein.

05:45

We go back to HDU to see how Mr Singh is doing. He’s tolerating the CPAP well and he tells us that he’s feeling slightly better and is breathing slightly easier. His blood gas shows and improvement too. Satisfied, we leave him to get some rest.

06:00

There’s nothing really pressing for me to do now and I’m feeling really exhausted. I’m wary that I’ll have to drive home at the end of my shift so I head off to try and get a little sleep. Doctor’s working patterns have changed from “on call” to full shifts. This means that we are meant to be working all the time we are present in the hospital. Hospital management have therefore taken the “on-call rooms” away from junior doctors. This means that when your night shift does get quiet, there are no beds to sleep in. Junior doctors do still have the Doctor’s Mess thought and this is where we all go to try and grab a little shut eye.

I enter the mess and all the lights are off. The large sofa is occupied by the Obs & Gynae house officer who is snuggled up with someone I’ve not met before. Judging by his snores, I doubt there is any hanky-panky going on. The surgical SHO is sprawled out on one of the small sofas. The surgeons always seem to be in the mess during the night – this is mainly because we anaesthetists keep telling them that they’re not allowed to operate through the night unless it’s life or limb saving surgery. Fortunately for me, the other small sofa is free and I curl up and quickly nod off to sleep.

07:05

I’m awoken about an hour later by a pager going off. I come out of my daze and realise that it’s not my pager, but that of the Obs & Gynae house officer. She gets up, gives whoever she was sharing the sofa with a quick kiss and leaves the mess.
I decide that I’d better get up anyway and wander back to the Intensive Care Unit. VJ is there reviewing all the patients ahead of the morning handover to the day team. I have a look at Mr Singh. He’s sleeping. His latest arterial blood gas shows that he is continuing to improve. I very much doubt that he’ll need a ventilator now and I hope that he’ll be well enough to go to a normal ward within the next 24-48 hours.

Coffee in hand, I go up to the anaesthetic office and fill in my form for some annual leave over the Christmas period and leave a note for the anaesthetic secretary regarding a query I have over the rota.

08:15

My shift is over. I meet Mel, who has just arrived for another day shift. I tell her briefly how my night was and then she goes to work seeing the patients booked on the morning’s Emergency Surgery list. I leave the hospital main entrance and head towards the car park. As I walk I smile because I know that soon, I’ll be fast asleep in my own bed.

Stupidity

Occasionally you hear about something that is just so stupid that it takes your breath away. 13-year-old Hannah Jones has spent much of her life in and out of hospital as she’s had leukaemia. Her heart is now failing and she has been offered a heart transplant. Hannah, however, has had enough.

She knows that the heart transplant may or may not be successful. Even if it is successful, she knows she’ll probably need another one before the end of her teenage years. She knows that the anti-rejection drugs that she’ll have to take after the operation carry a significant risk bringing her leukaemia back and she knows full well the pain and suffering that lies down that particular road. On balance, Hannah, with the support of her parents said, “No, thank-you. Let me be. If I am to die, I’m going to enjoy the rest of my days rather than spend them in a hospital bed.”

So far, this is another of those sad stories that you come across from time to time if you work in a hospital. However, somebody in the Primary Care Trust didn’t like Hannah’s decision. Somebody thought that she shouldn’t have the right to decide what was going to happen to her own body. As a result, Hannah was threatened with being taken away from her parents into care and forced to have the operation against her will.

It’s really unbelievable. The courts have seen good sense and have respected Hannah’s decision, but all the hassle and anguish that comes with a court case could have been avoided if people had just listened to Hannah in the first place. After all, isn’t that what the NHS is supposed to be about? Listening to our patients and making their care our first concern?

The mind boggles.

I need a hero

If I look back at my time through medical school and so far as a junior doctor, there have been a string of people in the medical profession that I’ve really looked up to and admired. I’ve had the good fortune to work with some unbelievably intelligent, caring, hard-working people and I think I’ll be forever grateful for the little tips and all the advice they’ve given me. I’m not just talking about direct clinical care, but about all the other things that come with being a doctor such as practical tips, emotional support, and sometimes just sticking up for you when others are trying to pull you down.

I now firmly believe that having good role models has been, and still is crucial to my training so far as a doctor. Don’t get me wrong, I’m not saying that every doctor is to be admired – I’ve come across my fair share of arseholes with a medical degree, but, like having good teachers, you never forget the good doctors you’ve worked with in the past.

At my current hospital, I’ve worked a few times with Dr Harrison who is a rather large lady from Barbados. I have to say I love her to pieces. Not in a romantic way, but I really admire the way she works. She’s a fantastic anaesthetist and she has taught me loads about working with children, about nerve blocks, about vascular access and about anaesthesia in general. But it’s much more than that. I really respect her manner, her patience, the fact that she obviously really cares about what she does and about the people she works with, her good humour and general good nature.

Maybe I’m a bit prone to hero-worship, but when you work with people as fantastic as Dr Harrison, I think the admiration is well deserved and I do actually find myself saying to myself, “One day, I want to be like you.”

In which I'm left flabbergasted

I’m on the ward seeing patients before the morning’s general surgical list and the next patient is Mr Barnes, a 52-year-old man who’s come in to have his hernia repaired.

“…Mr Barnes, aside from the problem with the hernia, do you have any other medical problems?”

“Yes, I’ve had lung cancer.”

“Lung cancer?”

“That’s right doc.”

“Is it still a problem for you?”

“No doc, I’ve had it treated and they tell me it’s gone away.”

“Right… What treatment have you had?”

“I had radiotherapy and chemotherapy for a few months last year.”

“And do you still see the cancer doctors”

“Yes, I saw him about three months ago, but he said that it’s in remission and there’s no need to do anything else about it.”

A bit later on

“Do you smoke sir?”

“Yeah.”

“How much?”

“When I try to cut down, about ten a day, but I’m smoking about twenty a day at the moment.”

………………………………………………………………………..

I really, really don’t understand some people. I’ve tried to get my head around it but I really can’t fathom where Mr Barnes is coming from.

I know that some people find giving up smoking really hard, but this is totally ridiculous. I could have understood Mr Barnes’ smoking more if he had terminal cancer and he’d said something like “I’m going to die anyway, so there’s no point in stopping now – it’s too late for that.” But he doesn’t have terminal cancer. His cancer is in remission.

Chemotherapy and radiotherapy is horrible ordeal to have to go through. It’s months of feeling awful, feeling weak, feeling sick, not to mention the emotional strain it puts on you and the people around. Why on earth would anybody put themselves through all that and then continue to smoke afterwards?!? So he can go through it all again in a couple of years’ time with his brand new cancer?

Mr Barnes is one of the lucky ones. He’s one of the few that actually get batter from their cancer and didn’t die along the way. He’s one of the people that we in the medical profession talk about when we say “To see Mr Barnes walk out of hospital for the last time after all those months of heartache, knowing that he’s actually got better, makes it all worthwhile you know. For all those that don’t make it, it makes it means so much to see somebody come through it.”

But Mr Barnes continues to smoke. He continues to spend his money on those little white sticks that gave him the cancer in the first place. In the not-too-distant-future, he’ll return to hospital either with a recurrence of his old cancer or with a new cancer and we’ll have to try and make him better again. What on earth is the point?

Sometimes I don’t know why we bother. This strikes particular chords at a time when there’s so much debate about top-up payments for cancer treatments because the NHS can’t afford to pay for everybody. If patients like Clive Stone really want to know why the NHS can’t afford to pay for their treatment, they should just pop in and have a word with people like Mr Barnes.

That’s where all the money’s gone.

Saturday Night

Things a 16-year-old girl should be doing at 9pm on a Saturday night.

• Voting for her favourite person to win X-Factor
• Arguing with her parents who tell her “You are NOT going out dressed like that.”
• Chatting with her mates and explaining why her new boyfriend is so fantastic
• Posting pictures of her cat on Flickr
• Downloading the new Kings of Leon song
• Getting excited as she sits in the cinema and the opening credits of High School Musical 3 come on the screen
• Chatting to her Irish friend on Bebo
• Standing nervously in the queue to get into the new bar in town and hoping the bouncers don’t spot her fake I.D.

Things a 16-year-old girl should NOT be doing at 9pm on a Saturday night.

• Lying cold and lifeless on an A&E trolley as the priest reads her last rites.

Through the darkness

I’ve been working as a doctor for a few years now which means that I’ve a few years of working night shifts. You’d think that after all this time I’d know the best way to re-adjust my body clock so I can work through the hours of darkness but this is really not the case.

The trouble with working all through the night is that you invariably end up deprived of sleep, no matter how hard you try to sleep during the day. On top of that, it’s actually pretty difficult to eat properly. You don’t really feel hungry when you’re on nights, but a couple of nights in, you’ll start to feel really weak, irritable and spaced out and you’ll realise that it’s probably because you hardly eaten anything for 48 hours.

I’ve tried various strategies to get me through. I’ve tried forcing myself to stay awake the night before, I’ve tried trying to sleep whenever possible, I’ve tried sugar, I’ve tried caffeine, I’ve tried exercise and I’ve come to the conclusion that there is no good way to flip your body clock to working nights and then flip it back again.

My current strategy is to eat two largish meals – one before I set off for work in the evening and one before I leave work in the morning. I’ll also try and eat something at around 01:00 and if it gets quiet, I’ll try and snatch some sleep. I don’t think getting through nights becomes any easier, but I would say that these days, I’m more prepared for how crap I’ll feel.

On a roll

Now I’ve passed my exam, it means that I’m going to be an anaesthetic registrar in less than a year’s time. This means that out-of-hours I’ll be the most senior anaesthetist in the hospital and have to look after just about everything with no immediate back-up. It’s quite a scary prospect, so for the next few months I’ve decided to try and get as much exposure as I can in the aspects of anaesthesia and intensive care that I feel I don’t have much experience in. Effectively this is just about everything at the moment, but right now I’m trying to concentrate on specific procedural skills, so I’ll feel much more willing to do things out of hours. Specifically, I’m focusing on spinal and epidural anaesthesia.

This is one of the many aspects of anaesthesia that I find truly amazing. Basically, with an injection in the back, patients can have their operations and be completely awake and lucid throughout. You can sit next to them and have a conversation about gardening whilst they have their leg sawed off or their womb sliced open and they are completely pain-free throughout the whole operation. It’s really quite incredible if you think about it.

I know this link makes it look very simple but actually giving the injection into the right place is very tricky though because you can’t see where your needle is going. I have to rely on my knowledge of anatomy and previous experience to get it right.

A while ago, I posted about having a bit of a crisis of confidence. I basically felt that I wasn’t as good as I’d have liked to be at some aspect of my job. Well, it’s now a month later and I feel rather different, I've got over myself a bit and now just want to get as much experience I can at stuff so I can get better at it.

I clearly remember being a house officer in my first few months of my medical job. We had an elderly gentleman, Mr B., on the ward who had terminal cancer. He needed a venflon so we could give him some IV fluids to prevent him getting dehydrated. I tried once; I failed. I tried again; I failed. I must have looked really dispondent because he said to me, "Son, if you fall of a horse, the first thing you must do is get back on it again." The third time, I succeeded in getting a venflon in. Unfortunately, Mr B died of his cancer a couple of weeks later, but his words have stayed with me to this day.

A couple of months ago, I often just could not do spinal anaesthetics. I’d attempt and fail and then have to ask the consultant or registrar to take over. In the last few weeks, however, I’ve got much better at it. All of my last five attempts have been successful. All five patients had no pain for their operation whilst being awake. I’m on a bit of a roll and am feeling a bit pleased with myself at the moment.

On another note, I feel that my getting the exam out of the way early is going to be really beneficial for me. Now, I really do feel like all the pressure is off and I can get on with the business of learning to be a really good anaesthetist. Also, from a career point of view, it gives me time to get involved with audits and teaching. This is good because I really enjoy teaching and it will look good on my CV. All-in-all I feel that for the next few months, at work I can relax a bit and really start to enjoy myself.

A shot in the arm

For those of us who work in the NHS, it’s something that divides opinions as neatly and effortlessly as Bob Dylan or Marmite. It comes around at roughly this time every year and the chatter I hear around the wards and operating theatres suggest that this year is no different. You hear snatched snippets of conversation that go like…

“Are you going to do it? I’m not sure if I should I know Adrian’s doing it but he’s a bit older than me”

“There’s no way that I’m going to do it – I don’t see the point and I’ll just feel rough afterwards.”

“The way I see it is that it’s there to help us so we may as well take the opportunity while it’s there.”

“I can’t believe you’re going to do it, why on earth would anyone want to do that to themselves?”

I’m talking, of course, about the annual flu jab. This gets offered around this time of year to all health care workers as we are deemed “at high risk” because of our exposure to sick people. There is a problem though. The flu vaccine will inevitably make you feel really rough for a couple of days. You’ll get a runny nose, a cough, achy joints – in short, you’ll feel just like you’ve got the flu. It’s not as bad as the real thing though. I remember one Christmas when I was in my mid teens and I came down with the flu really badly. It was horrible. I literally couldn’t get out of bed for a couple of days and I felt hideous for about a week.

As a result, I see things like this: actually getting the flu is far worse than feeling rough for a couple of days. If the shot in the arm helps prevent me from the misery of the virus, then I’m all for it.

Needless to say, I was at the front of the queue when the Occupational Health Department opened their doors today.

200

I would like to say a huge thank-you for your messages of congratulations on my last post.

You know, I went into the city centre on Sunday afternoon. I took the bus in and I walked around for a bit. Not for any reason in particular, just because I could. I really feel that there has been a huge weight lifted from my shoulders. I was actually laughing to myself when I was walking through the park. I was laughing because I didn’t have to go home and try and remember the breakdown products of sevoflurane or the pKa of fentanyl or anything like that. What felt even better was that I didn’t feel guilty about not studying and didn’t get stressed that this was time I was wasting in which I could be learning those crucial few factoids that could make the difference between a pass and a fail. It felt great.

This is my 200th post on this blog.

I started this blog back in spring 2007 (halcyon days according to the politicians and financial experts, though I think several thousand junior doctors would disagree) and I honestly didn’t think that I’d still be doing it a year and a half later. There was no political motivation behind the blog (there still isn’t), I just started to write because I enjoyed writing for writing’s sake. I still do enjoy writing, and I guess, I’ll keep blogging as long as it’s fun for me.

Back when I started, I wasn’t to know just how spectacularly I’d be dicked around by MMC and I was probably pretty keen to continue working in general medicine, but had started to think seriously about switching to anaesthetics. My life has changed a hell of a lot since I started this blog (generally for the better, I think) and I think I’ve changed rather a lot as a person too.

I’m clearer about what I want from my career and my life in general. I’m less willing to be pushed around by others who want to make their own lives easier. I’m also much less scared now. I’m less scared by what I could potentially be asked to deal with. When I first qualified as a doctor, we used to joke about the tag line from the old Dr Pepper ads – “What’s the worst that could happen?” because we were really scared about being harming our patients or being powerless to prevent their demise.

Now, after being an anaesthetic SHO for a while now, I’ve seen “the worst thing that could happen” again and again and again. I’ve seen people vomit blood and keep on vomiting until they die because they literally have no blood left. I’ve a little girl rushed into A&E but amid the drama and the frantic activity, there is one unchanging fact – the baby is dead. I’ve seen people with the most horrific injuries from accidents (including a partial decapitation) and every time something this awful happens, I’ve seen the hospital staff try to move heaven and earth to help these people who come to our door. The point is, I’ve had to cope with it and I have to try and be of some use to these people. Every time the on call pager goes off and I get the “Could you please attend A&E resus immediately” I know that “the worst that could happen” is probably already happening and they’re calling me to help them out.

This post seems to have turned a bit more introspective than I intended it to. Being a doctor isn’t all doom and gloom and blood and guts – it’s actually quite fun. I enjoy chatting to the patients and the staff every day. I enjoy feeling that there are a number of people walking around the UK right now whose life is better in some way because of something I’ve done. I enjoy feeling that every day I make a difference sometimes in a big way, but more often in a small way.

I may bitch and moan about things that frustrate me about my work but, at the end of the day, I love my job and, all-in-all, I wouldn’t really want to do anything else.

Anyway, enough blabbing, I’m off to bed – I’m on call again tomorrow.

Results Day 2

Friday 12:48
I’m sitting having lunch with a couple of the other doctors that I work with.

“What time do you find out if you’ve passed?” Helen says to me
I look at my watch for the hundredth time. “In seventy-two minutes.” I reply
“I can’t believe you’re so calm about it. I’m really nervous about your results and I didn’t even sit the exam!”
“I’m not actually that calm about it at all, I’m just forcing myself to not think about it.”
“I’m sure you’ll be fine though – I have faith.”
“Thanks, but we shall see. It’s like VJ was saying earlier, I think with this exam, the first attempt has to be the best one. If I fail, I’ll have to do it again in January and the thought of having to do all that revision again is one of the most depressing feelings in the world.”
“And then there’s all the money that you paid to sit the exam in the first place,” adds VJ
“Yes, that as well,” I reply. “And also there’s the pride as well. I’ve made such a flipping song and dance about doing this exam that if I have to go round and tell everyone that I’ve failed, it’ll be just so embarrassing.”
“I wouldn’t worry about that,” reassures Helen, “not many people pass this exam first time, we’re just keeping everything crossed for you.”
“Cheers,” I mumble. “I appreciate that.”

Friday 14:00
I’ve started the afternoon gynaecology list with one of the consultants.

“Do you mind if I go see if the results are up?” I ask.
“Of course not, you go ahead.” I head towards the theatre doors and he says, “Michael, when you come back, I expect you to be smiling.”

I walk round towards the staff room where the computers are. I wasn’t really calm earlier on. I’ve been bricking it all day and now my heart is hammering in my chest and I’m absolutely petrified. I enter the password that allows me to access the internet at work and type in the web address for the Royal College of Anaesthetists. I find the results page and click the link you download the .pdf file containing the pass list.

I slowly scroll down to where my number ought to be. I remember doing this last time, but had forgotten just how horrible the moments just before you find out your result are. This time, I’d remembered my number off by heart so I knew exactly where it ought to be.

My number was up.

I’d passed.

It felt different this time. I didn’t shout or punch the air. I felt a huge wave of relief sweep over me. I sank my head into my hands and had to take a few big breaths. I’d worked so hard for so long and now it was all over. I couldn’t believe it was all over. I’d done it. I’d achieved what I set out to do. I’d done what so many people had failed to do and what so many people doubted I could do. I’d passed the FRCA primary at the first attempt, six months ahead of schedule. I think at this point I may have even shed a tear.

Then I started to smile and then to laugh and then to laugh even more. I stood up with a huge smile on my face and went off to let everyone know that I’d passed.

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

I’d also like to say a huge thank-you to everyone who wished me luck online. Just before the exam I really did feel like everyone, I mean everyone - family, friends, work colleagues and commentors on this blog - was rooting for me and I think knowing that really helped me on when the exam got really tough.

Thank-you

Leaving everything on the track

So this is it.

My bags are packed, my shoes are polished and soon I’ll be heading off to the capital to sit the second part of the FRCA Primary exam. Two oral exams and one 90-minute OSCE stand between me and the “pass” that I need to go on to become an anaesthetics registrar (or ST3 in new money).

I have to say that I’m not feeling too frightened or nervous by the prospect of having my knowledge picked apart by the RCoA examiners. I’ve been working incredibly hard over the last couple of weeks and to be honest with you, I’m REALLY fed up with it all. I’m sick of the sight of my textbooks and I can’t wait for it to all be over – for better or for worse.

With this exam I’ve realised that I’m not going to be able to know everything that they could possibly ask. I reckon that you could spend half a lifetime studying physiology and still get flummoxed by a question on some random cytokine and same applies to pharmacology. My simple aim has been to try and know enough about enough subjects to pass this exam. I have to say that I’m feeling quietly confident about it at the moment and I reckon that if I manage to keep my composure (easier said than done!), with a little bit of luck I should hopefully be OK. Of course, I’m just speculating – I won’t really know this until the results are published at 2pm on Friday.

I remember watching the Usain Bolt breaking the legendary Michael Johnson’s 200m world record in the summer and in an interview afterwards he said something really telling.

“The night before that 200 metres final I told my room-mate,
Maurice Smith, ‘I'm going to leave everything out there on the track
tomorrow,'”

He “left everything on the track.” He gave it his all and didn’t hold anything back at all.

In some ways I too feel I’m giving this exam my very best shot. I’ve used all my study leave and I’ve racked up over 100 hours of study in the last three weeks alone. I’ve really tried my hardest to cram as much as I can into my skull, but despite this I’m all to aware that there is a hell of a lot that I still don’t know. I’m going to give this my very best effort and I hope that it will be good enough.

The problem with “leaving everything on the track” is that I don’t know what I’ll do if I fail this exam. Like I say, I could hardly have worked harder for it, so failure kind of leaves me with nowhere left to go. But I’m not really contemplating failure at the moment to be honest, the prospect of having to pick myself up and put myself through all this again makes me feel physically ill. I’m not really into rap music but I think Eminem spoke volumes on “Lose Yourself” when he said “…success is my only motherfucking option – failure’s not…”

Whatever happens, I shall be glad when it’s all over.

No such thing as a free lunch

Back near the start of the year, I was feeling a little poor. Like a lot of people, I’d ended up being a little overgenerous at Christmastime, and I started the new year feeling a tad broke. One morning, I noticed a poster saying there was a free lunch for junior doctors that day in the doctor’s mess. I’m all in for a bit of free food, so I made sure I was in the mess at 12:30 to tuck into the M&S sandwiches.

The lunch was sponsored by one of these Independent Financial Advice (IFA) companies. This meant that, while we munched away, we had to listen to their reps talk to us about the state of our finances and what we needed to do to “help secure our financial future.” I’d heard similar things from similar companies several times since my med student days and I’d become rather cynical about what these people say.

Basically they bang on for about 20 minutes telling us loads of stuff we know already, then they start talking about how expensive university/mortgages/living costs are and then they try and flog us payment protection insurance. Daniel and Jane, the IFA reps, were no different. They were very charming, very attractive, wore nice suits and had expensive-looking haircuts and I could see how you could get swept along with all the “wise” words that they were saying.

Like I say, I was feeling a bit broke at the time and I was a bit more willing than normal to listen to any advice about how to make the money I earn go a little further. I booked an appointment and with Daniel a week or so later to discuss the state of my finances. I’ve heard for a long time from many sources that “over the long-term shares are a better investment that property” so I was quite interested in how the whole “investing in the stock-market” thing worked. Daniel and I met and I batted away his hard-sell of payment protection insurance and then I had a look at the share portfolio that he had put together for me.

He said that he’d selected “the investment funds that most suited my ambitions” and gave me a lovely portfolio containing lots of nice graphs and lots of stuff like “MultiPEP” and “+113%” and “convenient and tax-efficient way of investing” and there were lots of pages with lots of names and lots of numbers in very small print.

It all looked very impressive, but my problem was I still had no bleeding idea how it all worked. As far as I could see, the deal amounted to me giving Daniel £50 to £100 each month and then I may or may not get more or less money back at some point in the future… perhaps. I really didn’t “get” how investing in shares worked, so I was a little loathe to put my hard-earned money into something I really didn’t understand.

I have a few friends who work in the financial markets and when I meet them they seem to be very successful but when they start talking about “P&L accounts” and “asset ratios” I get lost very quickly. I’m sure it’s not actually that complicated, but I’m basically not at all interested in it, so I either tune out very quickly or change the subject back to women and football.

Anyway, the long and the short of it is that I didn’t buy any shares and put my £50 each month into an ISA instead. To his credit, Daniel agreed that that was probably the wisest idea at the time.

Fast-forward now to last Thursday evening. It’s about 18:30 and I’m just arriving home from work. I look around my place and it’s an absolute tip. I will confess that I have a tendency to go to seed a bit when I have a big exam coming up but I decide enough is enough and dedicate the rest of the evening to tidying up. Guess what I find? Yup, the share portfolio that Daniel put together for me all those months ago.

I’ve been following what’s been happening in the financial markets with a dispassionate interest (I want everyone who feels sorry for the city bankers to put their hands up now… anyone?... anyone at all?.... I thought not) so I thought I’d look on the internet about what happened to the funds that Daniel had advised me to invest in.

Guess what? Every single one of them was down by between 15% and 40% over the last year. If you include Daniel taking his fee and the fund managers and taxmen taking their cuts I would have been left significantly out of pocket. Now despite what you hear in the press, I don’t actually earn a vast amount of money and I would have been seriously pissed off if I’d decided to invest at the start of the year, especially knowing that my money had probably been spent by City Boys pouring Kristal over stripper’s arses in some lapdancing club in Soho.

Now, from what I understand, banks like Northern cRock, Lehman Bros and HBOS got themselves into trouble basically by investing in thing they don’t understand and as I sit here typing this, I feel like patting myself on the back for not making the same mistake that they did.

The other point I want to make is that it is Daniel’s job to pick the best places for me to invest my money. I have no idea if he’s still doing that job and I have nothing personal against the guy, he appeared to be a really nice bloke but he’s meant to be an expert. He earns a living and buys expensive suits on the basis of his “expertise.” The question is… If he can get it as badly wrong as he has done, do I really think that he’s competent in his job? If I did as badly in my job as he’s done in his, I shudder to think what might have happened.

Anaesthetist 1 Surgeon 0

We're halfway through a gall bladder operation

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

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

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

A night's sleep

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

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

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

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

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

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

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

After 15 minutes I go back to see Emma.

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

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

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

Support

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

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

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

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

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

Stages of Preparation

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

Stage 1: Denial.

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

Stage 2: Trepidation

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

Stage 3: Fear

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

Stage 4: Hope

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

Stage 5: Determination through the dark days

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

Stage 6: Consolidation

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

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

While I was away…

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

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

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

I need to crack on...

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

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

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

In which I lose the will...

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

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

Bank Holiday Monday

Today I learned (among other things):

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

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

Ain’t your bitch

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

“Hello?” comes the reply

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

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

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

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

“And what happened to that venflon?”

“It came out”

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

“I don’t know. It just came out.”

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

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

“Has your registrar tried?”

“No.”

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

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

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

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

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

“But…”

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

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

Room for improvement

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

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

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

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

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

1. Get rid of the anaesthetic room.

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

2. Automatic Doors

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

3. Printouts

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

4. Use Wireless Technology

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

5. Bleeps

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

A job for life

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

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

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

The future’s bright.

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

A crisis of confidence

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

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

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

This isn't how I imagined it would be

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

Let me tell you about what happened yesterday.

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

This was a definite “learning experience” for me.

It begins again

My reprieve is over.

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

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

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

The Olympics

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

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

Come on Team GB!

It goes on and on and on…

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

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

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

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

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

All Change

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

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

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

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

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

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

In which I find myself totally out of my depth

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

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

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

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

A quick glance tells me lots of important things:

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

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

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

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

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

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

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

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

Shit.

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

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

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

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

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

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

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

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

It takes them aaaaaaaaggggeeeeeeeesssss.

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

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

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

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

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

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

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

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

Like I say – it never rains; it pours.