Stepping Up

Tomorrow, I start work as a registrar. A registrar in Anaesthetics and Intensive Care, to give me my new job title. I'm about to make the step up from the ranks of "the junior doctors" to "the middle grades"

I’m starting a new job, in a new hospital (in fact, at TheBigTeachingHospitalDownTheRoad) with a greatly increased level of responsibility. I’ve now completed the transition from being “the doctor who knows when to get help” to being “the help.” Previously, I’ve known that if I found myself in a situation that could get out of control; that I could call on the anaesthetic registrar to come and bail me out. Now, I’m the bail out person and there’ll be no one around to bail me out if things go wrong. That thought is pretty scary.

It feels like I’ve come a hell of a long way in what seems like a vanishingly short period of time. Two years ago, I gave my first simple anaesthetic to a patient. From tomorrow, I’m going to be expected to look after the intensive care unit out of hours. I’m going to be expected to know what to do with all the life-support machines that the patients are on. I’m going to be expected to manage all the various inotropic infusions, the ventilators, the haemofilters and dialysis machines. I’m going to be expected to know what to do with intra-cranial pressure bolts, jet oscillators and all manner of complicated things. To be honest with you, I’m a bit worried.

I’ve got a slightly empty feeling in the pit of my stomach, like I’m standing on the top of a very high building, leaning over the edge. I’ve had this feeling before, I recognise it well. I had it when my Dad was driving me down for my first day of university. I had it the first time I stepped into a hospital as a medical student. I certainly had it on my first day of work as a doctor. I had it the first time I was fast-bleeped to A&E resus as a medical SHO. I had it the first time I was on-call for anaesthetics, and tonight, I’ve got it again.

It’s partly the fear of the unknown, but it’s mostly the fear of what can go wrong. It’s the fear of hurting people, of doing the wrong thing, of not being able to help someone who needs my help.

Perhaps I’m being a bit dramatic, I don’t feel anywhere near as scared as I did on my first day as a doctor. I actually feel that things are going to be OK for me and for my patients. I know that the consultants and the nurses will know that I’m new and that they won’t be expecting miracles from me. I know that I need to ask about things that I don’t understand, and I have a feeling that I’ll be asking a hell of a lot of questions initially. Given a choice, I would have preferred to have another six months as an anaesthetic SHO, but our training is not set up that way and I’ve got to make the step up now.

So here I am, swotting up on the Surviving Sepsis Bundles and wondering how I’m going to cope tomorrow when I walk on to the intensive care unit as “the new reg.”

Work is about to get a hell of a lot more interesting…

The European Working Time Directive (again)

So, the European Working Time Directive has finally come into force for doctors in training, and it’s in the news again. Last year I wrote about what I felt about the EWTD and why I think, overall it’s probably a good thing. I haven't really changed my opinion in the intervening time.

Basically, if you’re organised and the system is on your side, there’s an awful lot that can be achieved in 48 hours.

Swine 'Flu

I've outlined some of my concerns about the H1N1 pandemic before on this blog. The people at the Daily Mash made me smile today and realise that my concerns are certainly not shared by all...

Emma Bradford, from London, said: "I have definitely got it because my Blackberry said so. I shall be collecting my Tamiflu from the chemist and then taking advantage of a last minute recuperation deal to Menorca."
Tom Logan, from Finsbury Park, said: "I would say I'm about 30% sure I'm not feeling well, but I'm 100% sure that I have just come up with a copper-bottomed reason to extend my summer holidays.

Swine 'flu

I don’t know about you, but I’m quietly getting more and more concerned about swine flu. A month ago, the World Health Organisation declared a global pandemic. I know it’s been out of the media spotlight for a while, but that doesn’t mean that it’s gone away, far from it.

You see, initially we were finding 5 or 10 new cases each day in this country, recently there’s been over 100 new cases daily and this week, the department of health has said that so many people have it that they can no longer keep count. At the moment, for most people, swine flu is a minor disease, but there are a few things that are concerning me greatly.

1. As I mentioned earlier, the number of new cases being found appears to be snowballing
2. If you read about previous flu pandemics, it seems to be the pattern that the flu is mild in the summer time, but then comes back again with a vengeance in the winter and that’s when most people die
3. Word from the intensive care doctors is that in those who need ITU admission quickly develop kidney failure and multiple organ failure – basically, they get very, very sick very quickly and stay that way for ages.
4. If the pandemic gets really serious and comes to my corner of the UK, I doubt that we’ll have enough space in intensive care to look after these people.

I’m also becoming more and more concerned about my own safety because:

5. History shows that those that die from flu epidemics tend to be young, previously healthy men – like me.
6. If the pandemic does get worse then, as an anaesthetist, I’ll be the person called to intubate these people and put them on ventilators. This puts me at an incredibly high risk of getting the virus. Remember all the anaesthetists and other healthcare workers who got SARS for this exact reason? Do you remember those who died?

Dr Tse volunteered herself in taking charge of the SARS ward and delivering direct medical care and treatment for SARS patients in Tuen Mun Hospital. In the full knowledge of the enormous risks for herself in performing the procedure, she repeatedly carried out intubation of her SARS patients in distress. She had worked with exceptional dedication, steadfastness and commitment in a selfless and fearless manner. By voluntarily putting her own life in extreme danger in order to save others, Dr Tse displayed noble gallantry of the highest order in carrying out her last duties.

Doctors like me are expected to turn up to work and carry on. We are expected to do the best we can in whatever situation we find ourselves in, regardless of the risks that we face by doing so. Talking to my colleagues, I have no doubt that this is exactly what we will do – we will do the best for our patients – but as each day goes by and as the death toll keeps rising, the swine-flu pandemic is giving me cause for concern.

If I think about what could potentially happen with this pandemic, it gives me the chills. I really, really hope that it all fizzles out and things don’t get much worse that they are already.

I’m keeping everything crossed.

It's nice to have an audience

It’s lovely outside isn’t it? I think we’ve already had more sunny days so far this summer than we did in the whole of last summer. Or the summer before, come to think of it. I’ve been away on holiday and I have to say that it’s been a bit of a struggle to motivate myself and to get back into “work mode” this week.

I’m coming up to the end of my second year of anaesthetics and I must say that my initial concerns about working in the specialty have proved unfounded. Every day I’m at work, I find something new that makes me happy.

For example, today I was working with Dr Burrows for the first time. Dr Burrows has a reputation for being a curmudgeon. He has very high standards and if you happen to say or do anything dumb in his presence, he’ll certainly let you know about it. I guess you could say that he’s quite old school in that way. Rumours say that he’s been stopped from teaching medical students because he kept making them cry.

Anyway, this morning’s patient was in for major surgery and required invasive monitoring. Dr Burrows asked me which parts did I want to do and I immediately said “The central line and the epidural” and went off to get scrubbed up. I’ve put in a fair few central lines and epidurals in the last couple of years and I’m at the stage where I feel just about confident that I can get them into most people.

I set everything up and under Dr Burrows’ punishing stare, I go about placing the epidural and central line. They both go in beautifully first time with no mess and no fussing. Later on Martin, the ODP, says to me “Dr Burrows was quite impressed with you, you know. He said that you were very slick and very professional.”

I smile to myself before replying, “It’s a shame they don’t always go in that easily. You watch, the next one I do will probably be a disaster, but it’s nice to know that sometimes, things go really smoothly.”

And when you do things really well, it’s nice to have an audience.

I heard it through the grapevine...

I can find very few people who think that MMC was a good idea, but still, the juggernaught rolls on, messing up the lives of junior doctors and causing untold stress. One of its so-called "advantages" was to give us a fairer, cheaper and more stream-lined recruitment process so that 

a) Hospitals would employ the highest quality junior doctors to look after their patients

b) Junior doctors would have a transparant method of apply for training jobs and be able to compete on a level playing field.

After the MTAS fiasco in 2007, we were told that the recruitment process was going to be sorted out and that the system would ensure that the best doctors are appointed to jobs and that no patients would come to harm because of the changes that MMC brought in.

Do you think that these lofty aspirations have been attained? Let me tell you what I'm hearing through the grapevine.

What the consultants are saying:

“We’re really worried about what we are going to do in August. When the current batch of junior doctors moves on, we’re concerned that there’ll be no one to replace them. The deanery are meant to be sorting out appointing people and hiring SHOs and registrars, but they’re telling us that we’re only going to be given a couple of each. How on earth are we supposed to run a service and an on-call rota with three SHOs and two registrars? It’s ridiculous. We’ve tried advertising for non-training junior doctors, but nobody seems to want those jobs, so we never get any applicants. Who’s going to look after the patients? We’re all really worried. There’s a crisis coming and we don’t seem to be able to do anything to prevent it.”

 What the deanery are saying:

 “We’ve advertised for people, but we don’t seem to be getting many applicants for the jobs. Some of the people we do get applying for these jobs are certainly, shall we say… inappropriate. We can’t appoint people to positions we don’t think they’re qualified for. For some reason, there’s a shortage of decent quality junior doctors that we can give our SHO and registrar jobs to. All we can do is keep trying to advertise, but I don’t see how things can improve.”

 What the junior doctors are saying.

 “I somehow have to find myself a registrar job for August, but it’s really difficult to actually find where these jobs are advertised. You used to just be able to look at the BMJ for job adverts, but now you have to search every day on each of the 16 deanery websites. The websites are often un-navigable and confusing. Half of them, you have to register with – which is a hassle - but, even then, they still don’t tell you when they have the jobs out.

“Then the application forms are all different and they take a couple of days to fill in. Then after all that, you know that there’ll only be one or two jobs in the whole area and they’ve probably already been promised to “local candidates” anyway. You just get really disheartened after a while and feel like giving up. I don’t understand why they make it so difficult to even apply for the jobs in the first place. I think it must be some sort of screening mechanism. You know ‘if you can find the application form – then you’ve done most of the hard work and we’ll probably offer you a job!’”

So there you have it - MMC a fair and transparent way to ensure that the best junior doctor are appointed to training jobs. The system is working well!

Did you hear about the one with the GP, the Black & Decker drill and the boy with a hole in his head?

 No, this is not some macabre tale from a horror film, but about a story that broke earlier in the week about Nicholas Rossi, a boy who fell off his bike and bumped his head. He developed signs of severe bleeding into his brain (similar to that which killed Natasha Richardson), and the GP, saved his life by drilling a hole through his skull with the only drill he had available.

 This story has made me stop and take note for a couple of reasons. Firstly, I deeply admire Dr. Carson, the GP involved, for what he did. Making the diagnosis of an intracranial haemorrhage in these circumstances is not actually very difficult for a trained doctor to do. We also know that to save a patient in these circumstances, you need to relieve the pressure in the skull and this can be temporarily achieved by drilling a burr hole into their skull. Actually doing it is a different matter. It doesn’t take a great deal of imagination to realise that you can do untold damage to someone by drilling into their brain. It takes a cool head, a steady hand and, most importantly, you need to be convinced that you are doing the right thing for the patient on the other end of the drill bit.

 Dr Carson is, quite rightly, being lauded as a hero but – here’s the irony – if Dr. Carson had been working as a GP in Britain, or even as an A&E doctor a district general hospital in Britain, he would be being hauled over hot coals right now.

 Reading this story in the press, you’d think that these events happened in the deepest, darkest outback and infer that if Nicholas had fallen off his bike in the UK he would have got to a big hospital quicker, making the Black & Decker unnecessary. You’d be wrong, very wrong indeed. Let me explain.

 Dr Carson’s rural hospital was 105 miles from the nearest Australian neurosurgical hospital. I work in a hospital about 60 miles from the nearest British neurosurgical hospital. 105 miles by helicopter and 60 miles by road have roughly the same journey time, if anything the chopper will get you there slightly quicker. What I’m saying is that my hospital is effectively just as isolated as Dr Carson’s. We are no closer to the neurosurgeons and their expertise here than he is in Australia. Admittedly, we have some posher drills here, but I don’t think we have a proper craniotomy kit and I’m certain that even if we did, there’d be nobody here that knows how to use it.

 My point is that a 13 year old boy with a head injury coming through the A&E doors at my hospital is effectively in the same situation that Nicholas Rossi was in Australia, and, I’ll tell you this much, this sort of scenario isn’t uncommon. In the last 18 months or so, I have seen three people come through into A&E resus with similar symptoms to Nicholas (head injury, altered consciousness and a blown pupil) when I’ve been on call. The difference is that not once have I or any of my trauma colleagues got the drill out. Not once has anybody even suggested getting the drill out.

 All three of them died.

 I find it quite shocking when I see it written down in black and white like that, but it’s true. (edit - to be fair, two of them had other, severe injuries elsewhere)

 The reason that we don’t drill into people’s skulls in my hospital is not because we don’t know what to do, it’s because we’re not allowed to do it. Trust me, if I attempted a burr hole in a patient like Nicholas in our A&E, I would undoubtedly be in huge trouble - even if I managed to save the patient’s life. I would have had the book thrown at me. I would have been accused of “acting outside my clinical competence” of “being arrogant and without insight” of “putting the patient in danger” etc… etc… etc…

 I would have no doubt been suspended from working as a doctor and referred to the GMC. And this would be if the patient survived. If the patient died (which, lets face it, is by far the most likely outcome in circumstances like this), I could be struck of the GMC register and possibly put up for a manslaughter charge. Regardless of whether or not the patient lives, very few would be lauding me as a hero. I would be at best a pariah, at worst a prisoner.

 I seriously doubt that anyone would have stuck up for me either. Not the anaesthetic consultants, not the A&E staff, not the neurosurgeons, certainly not the lawyers and, if the boy died, probably not even his family would have done.

 It’s a sad state of affairs that here, in the UK, we’d rather let someone die than attempt to save them by doing a procedure that we know is required. Once again, my hat goes off to Dr. Carson.

Caught unaware

Another afternoon on call and I’m at another cardiac arrest call. I’ve intubated the nonagenarian in question and am standing, giving the AMBU-bag an occasional squeeze whilst waiting for the medical reg to decide that this poor chap’s had enough and we should cease CPR.

 The nurse who’s performing chest compressions suddenly turns to me and says, “Are you humming?”

 I realise that I have been. I’ve been humming the same song that’s been going round my head for days.

 Caught unaware, I blush a bit and admit, “I suppose so.”

 “Are you humming for me or to yourself?”

 “Oh, only for me,” I say, “I’ll be quiet now.” The nurse smirks and refocuses on her chest compressions.

 Now it’s the next day and the same, unbelievably catchy song is still going round my head. For your information, I’ve posted it in the video clip below. Beware though, listen more than once and you too may find yourself subconsciously humming it in the most inappropriate of situations…

Anatomy of a day shift

A mere six months after the first post in this series, I’m going to continue my Anatomy of… series and tell you about a normal working day.

 Anatomy of a Day Shift

 08:05

 I pull up into the hospital car park, grab my bag and make my way towards the main entrance. When I was working as a junior physician, we started work at 9am. Anaesthetists start work an hour earlier, which gives us time to pre-assess our patients before the operating theatre lists start at 9. I’m well used to the earlier start now and one of the good things about it is that there’s always plenty of space to park in the hospital car park and I don’t have to drive around it for five minutes every day trying to find a vacant spot.

 08:10

 I’ve decided to come to work “casual” today, so I change into some scrubs before I go and see the patients. At our hospital, there is a distinct shortage of “medium” and “large” scrubs, but plenty in the “XXL” and “gigantic” sizes, but today I’m lucky. I quickly change into the scrubs and head out to find a copy of the anaesthetic rota so I can find out where I’m working.

 08:11

 

Chair Dental

Dr McAndrew

Dr Anderson

 Fair enough. I actually really quite enjoy chair dental lists. When children need teeth extracting under general anaesthesia, they can come to one of the chair dental lists. What’s meant to happen is this: The child enters the room with their parent, sits in the dentist’s chair. The anaesthetist gives a quick gas-induced general anaesthetic, the dentist whips out the offending teeth, the child wakes up and then goes home. It’s very quick, it’s very simple and I really enjoy meeting kids, so I find these mornings really good fun.

 It takes ages for the nurses to get all the children checked in and prepared so the chair dental theatre list never starts on time. The children have all been seen in the pre-assessment clinic so there’s little point in me going down there and waiting, I just get in the way. I make my way to the doctor’s mess to have some toast and a cup of tea.

 08:50

 I wander into the theatre and say hello to the theatre team. Catherine is the dentist today, and she’s in a particularly joyous mood. Soon after I arrive Dr McAndrew, the consultant anaesthetist, walks in. I like this man. He’s coming up to retirement and is pretty much the embodiment of the phrase “old school.”

 “Look, Michael,” he says to me. “You’ve done this list before with me haven’t you?”

I nod the affirmative.

“So you know that it’s basically fucking boring. If there’s anything else you want to do, or any other list that you want to join that you feel will be more interesting, please feel free to go off and do it.”

“Actually Dr McAndrew, I would quite like to stay and do this. I need to do more paediatric stuff, and perhaps we can do some of my Workplace Assessments this morning as well?”

“Fine, it’s your choice. Tell you what, you can do everything this morning and I’ll just hover in the background and make the occasional sarcastic comment. Show me your paperwork – let’s have a look at some of these forms you want me to fill in.”

The nurse tells us that she’s going to get the first child round and I prepare to give the first gas induction. 

The morning passes by pretty uneventfully. The children are well behaved and there were no major dramas. Actually, that’s not true. There were a couple of dramas – one of the children had particularly a particularly stubborn molar tooth. Catherine, the dentist pulled and pulled and huffed and puffed and then the tooth broke and she had to take it out in pieces. She had to stop a few times so I could give the kid some oxygen, but the tooth came out eventually. The last child of the morning was also the oldest (10), so I assumed she’d give me the fewest problems. I was wrong. She got to the stage where she was partially anaesthetised and then her heart slowed down dramatically to the point where it was dangerously slow (down to 32bpm at one point). Dr McAndrew lay the chair flat and I quickly put a cannula into her hand and gave her some glycopyrrolate and this sorted out the problem.

Interestingly, when these things were happening, at no point did I feel out of control, nor did I feel that the children were going to come to harm. These things now seem to me to be run-of-the-mill hurdles that the job as anaesthetist necessarily entails. I guess I’m become more experienced and I know exactly what to do in these situations, hence why these things worry me much less than they used to.

11:30

 The other good thing about this list is that it frequently finishes early. This gives me a chance to pester Dr McAndrew into going through a case-based discussion form with me. I have to say, that I’m finding these flipping pieces of paper more and more tedious. Apparently, the forms allow the deanery (who are in overall charge of my training) to tell which are the good doctors and which are the bad ones. I don’t believe this for a second, all they are tedious exercises in form filling. Dr McAndrew tries to make it a bit more interesting and we have a bit of a chat about various neuro-muscular blocking drugs, but really, I just want the piece of paper signed.

 12:00

 I head back to the Department of Anaesthesia, there’s a lunchtime meeting today, so the consultants, staff grades and trainees gradually filter into the meeting room. Most of the chat is about the pandemic ‘flu and the (lack of) training or advice that we’ve all received. It seems to me that the way my hospital is preparing boils down to “let’s all hope it doesn’t get serious, if we ignore it enough, maybe it’ll all go away.”

 12:30

The meeting begins, one of the other ST2 anaesthetists presents a recent piece of anaesthetic research and we have a discussion about it afterwards. Sometimes these discussions just end up with consultants ranting on about their own particular hobby-horse, but today’s was actually quite interesting.

 13:00

I pick up my copy of the afternoon list and I’m going to be flying solo this afternoon. I’m doing gynaecology day-case with no direct supervision this afternoon, the patients are all young, healthy women, so I’m not expecting any problems. I go through all the routine pre-op stuff with each of them and then head back to the operating theatres to prepare my drugs and equipment.

 13:45

Janet is the ODP working with me this afternoon. After briefing her about the patients and my plan for them, we manage to kick the afternoon theatre list off (just about) on time.

 14:15

Mr Jeffries, the consultant gynaecologist, has a SHO and a couple of medical students with him today, so there’s a lot of chatter going on down at the “surgical end” of the patient. Mr Jeffries’ style of teaching is to ask loads of questions at the students in rapid succession and then wait for some sort of response. At first, this seems to bamboozle the students and I smirk to myself as I see their worried faces – I remember being in their position only too well. The medical students are quite bright though, and they soon figure out that by picking just one of the questions that Mr Jeffries fires at them and answering that one, Mr Jeffries would forget he asked the others and then answer them all himself.

 16:30

The students have gone now, leaving Mr Jeffries and his SHO to finish the last case. The afternoon has passed calmly and uneventfully, just how I wished. I’ve had chats with Janet, Mr Jeffries and the rest of the theatre team and feel I know them all a little bit better now.

 17:10

This is my favourite part of the day. I go back to the ward where my patients are recovering after their operations. They’re all reasonably comfortable and they all thank me for what I did. I wish them a speedy recovery and then go and get changed. As I’m leaving work, Big Ed texts me to see if I’m up for tonight’s pub quiz. I’d forgotten that it was quiz night and was planning on going running this evening. I weigh the options up for a moment then decide that a pint and banter is probably more fun. I text back:

 Absolutely! See you at half 7

 And then get into my car and drive home.

Respect

I’ve been on call and I remember that I’ve run out of milk so, on my way home, I stop at the corner shop to get some.

 A couple of local lads who look in their early to mid 30s join the queue in front of me. They’re obviously in the early stages of a night out and are being loud, not rude or aggressive, just loud. One of them clocks me, and I must have been looking as haggard as I felt because he pulls his mate aside and says

 “ ‘Ere Jonno, let this geezer go first.”

 I’m not in any particular hurry so I reply, “No, no, you were here first” and gesture for them to go ahead.

 His mate has turned around to look at me and adds, “Nah mate, after you.”

 “Thank you very much,” I say and step forward to pay for a litre of semi-skimmed.

 “Thank you very much,” laughs the first bloke as he does a bad impression of my accent. “Are you a student or something?”

 “No, a doctor” I say.

 Immediately this bloke’s hand comes out to shake mine. “A doctor!” he exclaims and whistles gently. “What are you a G.P. then?”

 “No,” I reply, “an anaesthetist.”

 He enthusiastically shakes my hand again, “you guys do a great job.”

“Thank you,” I say. “Enjoy your night, fellas” I add as I turn to leave the store.

 As I’m walking out a hear his mate saying, “Wow, a real doctor! Can you believe it…” and I smile to myself as I make my way home.

Dear Nurse

Dear Nurse,

We are not going to take this old man to the CT scanner. You asked me why and I told you the reasons. He is a 91-year-old nursing home resident. He has a GCS of 3, his right pupil is fixed an dilated, his blood pressure is 212/95 and he has a heart rate of 54 bpm. The paramedics say that he had a dense left hemiparesis when they arrived and now he is unconscious.
I can see that you have a smart navy blue uniform and your badge says that you are the "Acute Stroke Lead Co-ordinator" or something, you are obviously a very important person. You can threaten us with clinical incident forms all you like, but I totally agree with the med reg on this one, going to the scanner would be a pointless waste of time, money and effort. There's no need to quote the NICE guidelines at me, I know what they say, but sometimes you have to ignore the guidelines.
Unfortunately, this man is going to die - CT or no CT - and what we should be doing right now is trying to make his last few hours as comfortable as possible. He needs care and to be allowed to pass away with dignity. He does not need a CT scan.

regards,

Dr M. Anderson

Something that made me smile

I guess I'm really sad, but I actually find this quite funny.

I should have got it done years ago

Walking down the corridor I spy Andy, one of the surgical SHOs who gives me a wave. He’s just come back from a holiday in Spain and is looking extremely orange tanned.

“Hey mate, how was the trip?” I enquire

“Absolutely brilliant,” comes his chirpy response. “Seven days with nothing to do apart from lounge around and drink beer.”

“Nice one, I’m almost jealous.”

“You ought to be.”

“And you seem to be doing a reasonable impression of Dave Dickinson at the moment…”

“Hey… don’t you start knocking our Dave! Anyway the tan’s not the only thing I got out there”

“Oh really? What else did you get? The clap? I’ve told you about this before…”

“Cheeky twat!” and he punches me on the arm. “No, I was talking about this…” And he gives me a conspirational look and rolls up his shirt sleeve to reveal a rather large tattoo on his right arm.

“Oh, you got it in the end.”

“Yeah, what do you think?” I study the design for a moment. It’s actually rather a good one. Admittedly, it doesn’t really go with the cuff linked shirt that he’s wearing, but with a different outfit I reckon it’d look really good.

“I like it,” I conclude. “It’s a bit bigger than I thought you were going to go for, but I think it looks really good.”

“Yeah, I thought there’s no point getting one unless it’s a big one and I really love it! I should have got it done years ago.”

“Well, you did keep banging on about it for ages, so at least I don’t have to listen to that anymore. But honestly, it looks good. I’ve got to get back to ITU though, I need to put a central line in before the patient goes to the CT scanner at 11:00. I’ll catch up with you later.”

“Yeah, see you mate,” replies Andy and off he flounced back towards the surgical wards.

What a way to start the week!

So, I arrive at work today feeling all refreshed and keen after the long weekend. It’s just after 08:00 and I walk onto the intensive care unit, where I’ve been rostered to spend the day. The consultant, Dr Amduno, is already on the unit and as I walk on, he says, “Michael, could you go down to the medical and give Nathan a hand with a patient down there? I’m sure he’ll fill you in with all the details.”

 “Sure,” I reply and do a U-turn and head towards the medical unit

 Nathan is another anaesthetic SHO and he’s been working all night. When I find him, he’s with one of the registrars, fiddling with the portable ventilator. Nathan tells me that he got fast-bleeped to see this man who was fitting. The usual treatment hasn’t worked, so he intubated the patient and was in the process of preparing him for a transfer to the radiology department for a brain scan.

 Nathan has got the man’s physiological parameters under control, so there wasn’t a great deal for me to do. I made myself useful by helping roll the patient so we could sort out his knotted hospital gown.

 Nathan looks after the patient’s  head and I grab the man’s hips. With the help of a couple of nurses, we roll him onto his side. As we hold him in that position while another nurse sorts out his gown, I feel something warm and wet against my leg.

 I’ve got a bad feeling about this, I say to myself. When we roll him back and I let go of his sheets, I see that there is indeed a large damp patch on my right thigh. I touch the patient’s sheets again. They’re soaked. Oh no. I pull a face and look at the nurse.

 “That’s not saline is it?”

She looks at me sorrowfully, shakes her head and replies, “I don’t think so.”

 I look at the clock. It’s 08:14. I’m less that a quarter of an hour into the working week and I’m standing in clothes that are damp from a stranger’s piss. Whoever said that being a doctor is lamorous work is definitely lying. I wonder why they never show things like this on telly…

Refreshed and recharged

After a particulary laid-back, beery and very enjoyable bank-holiday weekend, I'm actually looking forward to getting back to work tomorrow.

Let's see what this week brings.

It's that time of year again

We had one of our regular teaching sessions at TheBigTeachingHospitalDownTheRoad today. I actually quite like these afternoons, it gives us a break from the day-to-day clinical work and also allows us to meet up with junior anaesthetists from other hospitals in the region and it gives us a chance to swap stories and just have a good old-fashioned gossip.

 There was something different about it today, though. When I arrived at the Postgraduate Centre at TheBigTeachingHospitalDownTheRoad, I was surprised to see that the foyer was really packed. It was full of smartly dressed young men and women and lots of them had a glassy-eyed, haunted expression. There were several young women crying and being comforted by their friends and it took me a moment or two to figure out what on earth was going on.

 Then it hit me. Of course! It’s that time of year again.

 We don’t have medical students at my current hospital, so I’m a bit out of the loop, but I’d like to wish all the final year medical students sitting their medical finals the very best of luck. I’m thinking of you.

Global 'Flu Pandemic

As a doctor who spends a lot of time looking after patients on life-support in the Critical Care Unit, I have a vested interest in paying close attention to the reports of the spread of the “Swine ‘Flu” epidemic.

 From the moment the story broke on Saturday morning, we’ve had people from the Department of Health and the Health Protection Agency on the telly and radio telling us that “the UK is the best prepared country in the world to deal with a pandemic.”

 I really hope that this is true and our preparation is sound, but the thing that’s worrying me is that no one seems to be telling me or my colleagues what the plan is. There doesn’t seem to be any advice about how we actually treat someone who becomes critically ill with swine flu. We haven’t been told what type of protective measures we should take to prevent the in-hospital spread of this flu or how to protect ourselves from it. Should we use special masks? If so, where do we get them from? What should the isolation policy be? What do we do with the rest of the inpatients? Should we come in to work if we start to feel a bit rough? The hospital is pretty much constantly full anyway, so what happens when we get a big influx of admissions with ‘flu? What happens when we run out of beds? What happens when the staff start getting ill?

 These are all questions that we’ve been given no official guidance on. Obviously, we’ll do the best we can and try to deal with situations to the best of our ability, but it would be nice to know what sort of special measures or help is available to us.

 The thing that’s really worrying me is that nobody in the hospital seems to know the answers to these questions either. The consultants don’t know, the critical care sisters don’t know, and word is that the chief executive only has a sketchy idea about how manage an outbreak in this town.

 Reading between the lines, what I gather from the radio is that there seems to be some sort of secret masterplan and I really hope that this is the case. I really hope that a whole chain of events swing into action once we have a suspected case come through the hospital doors.

 I’m covering intensive care next week and I want to know if there’s anything different I should do from normal if the medical reg bleeps me and says, “I’d like to refer you a 31 year old man for consideration of ventilatory support. He presented with severe ‘flu-like symptoms after returning from a holiday in the USA on Tuesday…”

Blood on the dancefloor, part 2

This is a continuation of this post. 

A bougie is basically a bendy stick, and when using one to incubate a person, you’re aiming to feel the stick running across the rings of cartilage in the patient’s windpipe – a bit like a child running a stick along a wooden fence. As I pushed the bougie down into this man’s body, I didn’t feel that sensation at all.

 “Are you in?” asks Dawn, the ODP, who is standing next to my right shoulder, with the endotracheal tube (breathing tube) poised in her hand.

 I don’t know if I’m ‘in’ or not. The bougie could be in this man’s windpipe, but equally, it could be in his foodpipe and, if I put the endotracheal tube into his foodpipe, he’ll quickly run out of oxygen and die. As this thought flashes through my brain, a surge of panic rises through my body. It feels akin to being suddenly woken from a deep sleep. My heart hammers against my ribcage and I actually start to feel faint. I need to focus. I clench my jaw and swallow and concentrate on what I need to do. I decided to do this to this man, so it's up to me to see it through to completion. I claim victory in my personal battle with my own emotions, a battle that lasted only a split second, and I look again into this man's mouth.

When I was putting the bougie in, my hands must have shifted slightly. Either that or the swelling and bleeding has got worse, because as I try to look down the man’s throat, I can no longer see what I thought I could see initially. It just looks like a bloody mess and I wonder if I ever really saw anything in the first place or if it was just my brain playing tricks on me and making me see what I wanted to see. 

I figure that taking the bougie out and trying again is probably not be the best thing to do, but I did remember something that Dr Harrison told me when I was first learning how to use a bougie. ‘The trachea isn’t very long, even in the tallest of men. If you keep pushing the bougie down the trachea, you’ll get to a point when you can push it no further. If you push I down the oesophagus, you can pretty much push it all the way in.’

 I push the bougie in further, and further, and further and it stops. I can push it no more.

 “Oh, you’re definitely in!” says Dawn, who’s been intently watching what I’ve been doing. She puts the tip of the bougie through the endotracheal tube and I take hold of it and push into the man’s lungs. A few squeezes of the air bag and I confirm that I’ve put the tube into the right place.

 "Well done!” says the surgeon and I breathe a large sigh of relief as Dawn tied the tube in place and Ken and I set about putting the man’s hard collar back on. 

One of the things that I’ve noticed when dealing with acutely critically ill people like this is that as soon as the patient is intubated, everyone calms down a couple of notches. It’s almost as if the team breathes a collective sigh of relief. I think this mainly because when you induce anaesthesia and paralyse the patient, obviously they stop screaming and thrashing around which means that it suddenly becomes much easier for everyone else to do what the have to do. That could be that cutting off clothing, listening to the chest, feeling a pulse, palpating the abdomen, phoning radiology or simply taking in information and thinking about what the next steps should be. Whatever it is, it’s easier to do when you don’t have a screaming, thrashing patient in front of you.

 I certainly noticed it with this man. I set the mechanical ventilator and sorted out sedation while the A&E consultant (trauma team leader) reassessed and went through her A-B-Cs again. When I suction down the endotracheal tube I get moderate amounts of blood back, and this confirms that my decision to intubate him was the right thing to do.

 The patient (turns out that his name is Carl) was actually quite stable from the point of view of his vital organs.  From a doctor’s point of view, one of the things that I quite like about dealing with trauma is that the management is relatively straightforward. What makes it difficult tends to be more the organisational and people-management side of things. With Carl, we were doing well. We quickly organised chest and pelvic X-rays and, whilst he was having these taken, I turned back to the paramedics and ask her again what happened to him.

 “Basically, he was in a bar and from what we can gather was allegedly assaulted by two or three other men. Apparently they were kicking him and stamping on his head and it took security and the police a long time to get them off him. When we got there, he was pretty much as he was when we arrived here. GCS at the seen was 15, but he was combative and the only sats reading we got was in the 80s.”

 Ugh, I think to myself. The bar in question does have a certain reputation for being really rough, but I’d never heard of anything this bad happening there. “Well, he’s certainly had a good going over,” I comment.

 “It’s OK to come back in.” The voice is that of the radiographer, letting us know that she’d finished taking her X rays.

 The paramedic stops me as I start to walk back towards Carl’s trolley “Can I just ask you something?” He looks rather tense, like there’s something playing on his mind.

 “Sure”

 “Well, when we tried to get a sats reading, it said they were 85%. I was thinking about putting in a NPA (naso-pharyngeal airway), but didn’t because of the state of his face…”

 I frown and scrunch up my face, “I wouldn’t have…”

 “No?”

 “No.” I gesture towards the motionless Carl, “He could have fractures to his face… to his skull… we don’t know. A nasal airway could have made things worse.” A slight smile starts to play on his lips, “You did the right thing,” I conclude.

 “Thanks.”

Carl needs a CT scan of his head to see if he’s bleeding into his brain and thus needs urgent neurosurgery. Someone gets on the phone to the radiologist and the radiographers go off to warm up the CT scanner.

Major trauma really is time-critical. The sooner patient receives treatment, the better their outcome is. If you have an interest in trauma, phrases like “the golden hour” and “the platinum 10 minutes” will be familiar. In situations like this, the clock really is ticking and every minute unnecessarily wasted is potentially detrimental to the patient. The thing is, it’s so easy to waste time. It’s really tempting to “stay and play” in the resus room. You can put in arterial lines and central lines, set up infusers, warmers, splints etc… etc… All of these things take time, but these things may not be necessary or even helpful to the particular patient in front of you. You can spend lots of time trying to “do every thing by the book,” but lose sight of the fact that the whole point of “the book” is to identify the patient’s injuries and get them treated as quickly as is humanly possible.

 Anyway, I’m digressing a little. I’ve learned that one of the key things you can do to avoid time wasting is to think several steps ahead, and I’m getting better at this. Whilst waiting for the scanner to come online, I busy myself with setting up the pumps and refreshing the infusions and that are going to keep him asleep while we move him. I recheck Carl’s vital signs, give him some intravenous fluids and then go off and check I have all the equipment I’ll need on the transfer.

 I’m going to stop now and not say any more about Carl and what injuries he had. The events I’ve described actually happened quite a while ago, but this ended up being quite big news locally and I don’t really want to say much more for worry of compromising Carl’s real identity.

 All I will say is that Carl had surgery and survived to walk out of hospital several days later. Though Carl will never have any idea about what the paramedics and hospital staff did for him that evening, it does give me a real sense of satisfaction to know that as I sit here typing this, he’s out there somewhere living the life that I helped to save.

Blood on the dancefloor

The last patient on the emergency NCEPOD list is sitting in recovery after his operation. He’s drowsy, but comfortable and I’m chatting to Sara, one of the nurses when my pager goes off.

“Trauma call – A&E resus immediately please… Trauma call – A&E resus immediately please… Trauma call – A&E resus immediately please…”

I sigh and roll my eyes at Sara. “Just when you think all the work has been done, something else happens,” I say.

She smiles sympathetically as I turn and make my way out of Main Theatres towards A&E. To be honest, I’d been expecting this. I hadn’t had any trauma calls on my last couple of on-call shifts so, on the balance of averages, I was due one today.

Dealing with major trauma is one of the things that really worries me as a junior anaesthetist. Over the past few months, I’ve been making a big effort to improve my trauma management and get more experience of managing patients with major trauma. One of the things I wanted to achieve by the end of my ST2 year in anaesthetics was to be much more comfortable in situations just like this, and to some extent, I’ve succeeded. If I’d been in this situation a year ago, I’d be absolutely shitting it, but as I round the corner into the A&E resus room, I feel in control of my own emotions.

The first people I see are a couple of police officers looking intently at the scene that was unfolding in front of them. I give them a brief nod and headed into the resus bay.

The scene that greets me is bad. Very bad.

A young man lies on the casualty trolley screaming unintelligibly. He’s trying to trash around and two paramedics are trying their best to prevent him from hurling himself onto the ground. The bloody footprints of the hospital staff have created a perverse mosaic on the floor of the resus room as they desperately try and get control of the situation. A nurse has the man’s left arm locked in his vice-like grip in an attempt to keep it still as the surgeon is trying to shove a cannula into the man’s vein. I glance at the portable obs machine next to the trolley. It’s impassive display reads:

HR: -?-
BP: -?-
O2 Sats: 84%

Like I say, this is very bad.

Ken, the A&E charge nurse is trying to give this man some oxygen, but he screams again and thrashes his head from side to side.

“Are you the anaesthetist?” Ken, asks me.

“Yes, I am” I reply as I scan the bay for a pair of gloves to put on. The only box of gloves I can see contain small gloves, this has been a recurring annoyance throughout my medical career so far. I squeeze my goal-keeper hands into the gloves, quickly connect together an anaesthetic breathing circuit and turn on the oxygen. Ken stands aside as I plant my oxygen mask onto the patients face.

The patient looks horrific. His face is massively swollen to the extent that he cannot open his eyes and I cannot open them for him. The whole of his head is completely covered in blood, he is bleeding from his scalp, his cheek, his nose and appears to be bleeding from somewhere inside his mouth. My fingers keep slipping off his face as I try to hold the mask on to enable him to breath the vital oxygen.

Paradoxically, in the few moments that I’ve been there, I’ve been reassured by the situation. It’s probably not as bad as it looks. The mere fact that he is able to scream and fight means that he is not at the end of the road yet so, while things are undoubtedly very bad, they’re not yet critical. The surgeon has secured IV access and has moved on to examine the man’s torso.

“Can I have some suction?” I say and Ken passes me the Yankeur sucker which I put into this poor guys’ mouth. I suck blood, clots and saliva away from the back of his throat, which enables him to scream even louder.

"What's happened to this guy?" I ask. One of the paramedics starts to tell me the story, but to be honest I'm not taking it in at all. The patient is trying to sit up again and I lose my grip of my oxygen mask, which tumbles onto the floor.

“AAAAAAAARRRRRRGGGGGGGGGHHHHH!!!!!!!” he screams, but I notice that his scream gurgles towards the end as blood re-accumulates in his throat.

“This is fucked,” I state. “He’s got loads of blood in his mouth, he’s not spitting, he’s not swallowing, he’s probably going to aspirate if we leave him like this for much longer – I’m going to intubate this guy.” No one disagrees with me, and I quickly try to formulate a plan of how I’m going to intubate this man without killing him.

“Ken, are you OK to hold the oxygen mask while I draw up some drugs?” He nods to the affirmative and I hand him the mask, peel of my blood-soaked gloves and go to the drugs cupboard. It’s locked.

“Anyone got the drug keys?” I say, but I’m ignored as the patient continues to trash around. “WHO HAS GOT THE DRUG KEYS?” I shout. Sometimes, you have to make yourself heard.

“They’re over here,” comes the voice of Mary, one of the nurses.

“Thank-you” I say as she opens up the cupboard for me. I take out the thiopental and suxamethonium and start to draw the drugs into syringes. This takes a few moments and gives me time to pause for thought. I figure that this situation has the potential to go from serious to critical to fatal very quickly. Taking this into account, I conclude that it’s worth getting as much help as I can muster. I’m going to need to phone a friend.

“Mary, could you please call theatres and ask for one of the ODPs to come down to resus.”

“Certainly,” she says as she heads towards the phone.

“Oh, and Mary, could you also please bleep the ITU reg (my immediate senior) and ask him to come down too.”

I turn my attention back to the patient.

“Thanks Ken,” I say as I take the oxygen mask from him.

I put the Yankeur sucker back into the patients mouth and hoover out more blood. As I do so, he coughs and sends a spray of blood and saliva into my face. I feel the warm fluid trickle down the side of my face and my stomach turns. I make a face at Ken and he gives me a sympathetic look. “At least I had my mouth shut,” I say. Thank God for small mercies.

“Right, everyone; this man needs to go to sleep.” I say loudly. “Ken, can we take his hard collar off, now? And what I’d like is for you to do manual in-line stabilisation [of his neck], when the ODP arrives, she can do cricoid pressure and help me with the intubating equipment and we’ll get some one else to give the drugs.”

“Sure,” comes Ken’s response and he manoeuvres himself so he can comfortably keep the man’s neck as still as possible while Mary and I take off the hard collar.

I put the oxygen mask back on his face and right at that moment, like a cavalry unit, both the ODP and ITU reg arrive.

“I’m going to intubate him,” I tell them.

“What’s his GCS?” asks Ben, the ITU reg.

“Twelve” comes the voice of some bright spark in the bay. I’m pretty sure that his GCS is much less than twelve, but now is not the time to start a debate about it.

I shake my head, “He’s got a mouthful of blood and he’s not spitting or swallowing.”

“Can he maintain his own airway?” asks Ben

“No,” I reply

“OK then, I’ll draw some drugs up.”

“I’ve already got them,” I say. “They’re behind me.”

Ben picks up the drugs and goes round to where the surgeon had secured an intravenous cannula.

“Is everyone ready?” Ben asks. We all affirm we are. “OK, I’m giving the drugs now… Thio is in” the man on the trolley stops trying to fight us and becomes suddenly very limp. “Sux is in” The patient’s muscles ripple under his skin in an uncoordinated dance as the drug works its way round his body and paralyses every muscle as it goes.

I know it’s down to me now. Thanks to us, this man can no longer breathe and I have a small window of time to get a breathing tube into his lungs before he starts to die. The room has gone eerily quiet and I know that all eyes are on me as I pick up the laryngoscope and put it into his mouth. I’m hoping to see his vocal chords. What I’m aiming to do is push the tube between the chords into his lungs. They say that intubation should be a calm, smooth process, but I can immediately tell that this is going to be difficult.

All I can see is a lake of bright red blood. I pick up the Yankeur sucker and try to suck it away. The lake recedes annoyingly slowly, revealing the anatomical structures beneath it. But this doesn’t look like it does in the textbooks. It doesn’t look like any other intubation I’ve seen before. Everything is swollen, everything is red and everything looks sort of… twisted. I can’t see the vocal chords. I can’t see where I’m meant to put the tube. Worse, I can’t see any of the things around the vocal chords that are meant to give you a clue as to where to aim. I can’t see the epiglottis, I can’t see the arytenoids.

“Fucking hell,” I whisper to myself.

“Sats are 92%” comes Mary’s voice.

This man is starting to run out of oxygen and I’m going to have to do something. I pull harder on the laryngoscope handle, hoping to improve my view. The man’s throat is starting to fill with blood again, but I can’t see from where. Just at the limits of my view, I can see something pale and bumpy. I think it’s one of the arytenoids, but I’m not sure. I have a decision to make now. Do I step aside and let Ben see if he can intubate this man or do I try and do it myself, knowing that if I fail, it will be even harder for Ben to succeed? I trust my judgement and pick up the bougie [an intubating aid].

“What do you see?” says Ben

“Tricky,” I reply

“Sats are 88%” comes Mary’s voice again

Things are really serious now, I know that I only have a few seconds left to get the tube down before his body runs out of oxygen. There probably won’t be enough time for a second attempt before he is genuinely hypoxic. I hear the surgeon say something about a tracheostomy kit and have to act.

I push the bougie down where I think it should go and hope for the best.

To be continued…

Let's get tattoos

“What do you think about it Michael?” I’ve just walked into the doctor’s mess at lunchtime and the person posing me this question is my friend Andy, a junior surgeon.

“What do I think about what?” I say as I pull up a chair and open up my lunchbox.
“I’m thinking of getting a tattoo – but I’m not sure if it’s a good idea. People might look down on me because of it and I’m not sure that people will like it.”
“What are you going to get?”
“I don’t know, some sort of pattern – here on my arm” he says as he point to his forearm.
“Personally, I think tattoos there are pretty cool. If you want one, you should go for it.”
“Yeah – but what if the bosses don’t like it?”
“I wouldn’t worry too much about that – it’s your body after all and you can always cover it up.”
“Bare below the elbows, Michael!”
“Oh yeah, I forgot about that, you’re quite right, though I think we should take the ‘bare below the elbows’ thing with a pinch of salt.”
“And people will see it when I’m scrubbing up and stuff.”
“You’ve also go to think about what the patients might think,” pipes up Jo, one of the medical house officers.
“To be honest, I really don’t think that patients care,” replies Andy. “It’s more what my colleagues think that worries me.”
“To be honest with you Andy,” I interject, “I know that personally, I’m far too fickle to have a tattoo, but if I wasn’t and I found one I really liked, I’d probably get it done. But it’s up to you. All I’d say is that you should decide if you want it and if you do, go for it and not worry too much about what other people think.”
Andy furrows his brow, “Hmmm… perhaps you’re right, perhaps not. Watch this space.”

I’ll be watching with interest.