Who is a doctor?

Beep Beep… Beep Beep…

My mobile phone shrills and I casually reach over and pick it up to read the incoming text message.

You have an appointment with Dr Kavelidis at 16:00 on 17/12/09. Please allow time for parking.

I furrow my brow in confusion. I haven’t made an appointment with my G.P. in fact I haven’t needed to see him in over a year. Besides, I don’t have a clue who “Dr Kavelidis” is, perhaps he’s a new G.P. at the practice. But it still doesn’t make sense I’m sure the GPs at my surgery are busy enough without having to randomly text people on their practice lists to trawl for business. Was this some sort of new QOF thing? Seems unlikely, I’m a healthy young man. Maybe FashionGirl has the answer.

“Darling,” I say and she looks up at me from the magazine that she’s engrossed in. “Did you make me an appointment at the doctors? I’ve just had a text telling me I’ve got an appointment in a couple of days and I never made one.”

She shakes her head at me and says, “No, I didn’t. Let me see that.” She has a look at my phone and says, “It’s odd isn’t it? Especially as there’s no “from” number.”

None the wiser, I delete the message and continue watching the telly. Last time I went to the GP, I did get a reminder text beforehand, so I assumed there’s been a mix up and I’ve go the text by mistake.

Two hours later, it hits me. I do have an appointment on Thursday, but not with the doctor, with the dentist.

I go over to the fridge where I’ve stuck the appointment card and have a look at the names. Sure enough Dr. Kavelidis’ name is on the card, just below "Dr. Chang" and just above, ironically enough, “Dr Anderson.”

So, it does beg the question, “Are dentists ‘doctors?’” On this evidence, apparently they are. It just seems a bit odd to me. Dentistry is incredibly competitive to get into. Like medicine, you need straight As at A-level and then you have to spend five years studying at dental school before you’ve earned the right to call yourself a “dentist.” So why on earth, after all that, would you want to call yourself “doctor”?

It’s not just dentists that are “doctors.” Apparently, these days psychologists are “doctors,” chiropractors are “doctors”, and even nutritionists are “doctors.”

Slag me off if you want, but I spent five years at doctor school to earn the right to call myself “doctor” when I treat patients and I find it rather annoying (and inappropriate) that people with no medical qualifications get to call themselves “doctor” when treating patients.

I know there’s a feeling in the modern NHS that “anyone can do a doctor’s job,” but it’s simply not true. The way I see it, if you think you can be a real doctor, go to medical school and graduate. That way, you’ll see for yourself how “easy” it is.

Now, I totally agree that a PhD is hardly a walk in the park either, and neither is a dentistry degree and I can see that people who’ve worked hard for years at these should have a title to show their achievement.

The solution, I think is to use a system like the do in the USA whereby medical doctors have the suffix MD after their names. I know that MD means something different in the UK, but now dentists, nurses, psychologists, chiropractors and nutritionists are “doctors,” sooner or later, every man jack is going to be a “doctor” and the term will be meaningless.

Dr. Michael Anderson MD

I like the sound of that.

Casualty

I’m not working this weekend, so I’ve been sitting in front of the telly with a can of beer (Grolsch is my tipple of choice at the moment). Disappointingly, there was nothing I particularly wanted to see on the box. Come Dine With Me didn’t appeal, and I detest the X Factor so much that I won’t even entertain the thought of having it on anymore (I’m seriously considering buying Killing In The Name Of…).

I flicked over to the Beeb and was greeted by the Casualty* theme. I can’t listen to that tune without wanting to say “Will everyone stop getting shot!” in a really bad cockney accent. Previously, I’ve said that I was no fan of medical dramas, but for some reason, I thought I’d give it a go. Maybe it’s because I had nothing else in particular to do or maybe it’s because I’ve just spent a month watching seven series of Scrubs, but I thought I’d see if Casualty had gotten any better since the last time I watched it.

I think it’s definitely improved. I was quite pleasantly surprised and even moderately entertained. Back in the day, Casualty always used to be about “guess the really predictable disaster” and tonight’s episode remained true to those roots. I can sum it up with: Man unscrews valve on bus/fluid starts leaking out/bus goes downhill on narrow country lanes/brakes fail/bus goes over cliff. I don’t think it’ll Casualty will ever top the classic “man in field/combine harvester” episode, but it’s good to see the producers continue to try.

It’s also good to see that at long last, the show has recognised the existence of us junior doctors. I’ve spent more time than I care to remember trying to explain to people that “junior doctor” and “medical student” are not the same thing and then explaining what we junior docs actually do all day. I think having us on telly will help a little bit. The juniors on the show all seem to be very attractive, much more attractive than any group of doctors that I’ve ever worked with, if a bit on the numptyish side.

All in all though, it kept me amused for three quarters of an hour or so, so it’s definitely a big step up on the last time I watched a medical drama on the BBC. I might even consider watching it again next week.

If anyone reading this and thinks that I really need to get a life and get out more, I totally agree - Big Ed has just texted me and now I’m off out dancing…

* “Casualty” is such an old-fashioned name isn’t it? I’d be interested to know if it’s still called “Casualty” any hospital in the UK today (I must see photographic evidence) because, as far as I was aware, they all changed their name to “Accident & Emergency” years ago.

Interestingly, more changes are afoot because it’s been decided that “Accident & Emergency” is now not a good enough name, so it’s going to become the “Emergency Department.”

In about 10 years’ time they’ll probably all go back to being called “Casualty” again. Who makes these decisions? What a waste of time and effort.

Scrubs

Almost exactly a month ago, one of my colleagues lent me the DVD box-sets of Scrubs Series 1-7.

I remember when Scrubs first started. I was still in medical school and at the time, loads of my fellow medical students were raving about how good it was.

I never really got into it though, mainly because, as far as I can recall, it’s never been on terrestrial TV in the UK (correct me if I’m wrong). I watched the occasional episode at mate’s places but would never have said I was a fan of the show.

Until now.

I think the show is absolutely fantastic, and it’s made me laugh out loud more times than I can remember. For those who don’t know, the series basically follows three American doctors as they progress through their training from their intern year through to becoming attending physicians and beyond.

I’ve heard people say that it’s “really realistic.” I wouldn’t go so far as to say that the show bears much resemblance to every day hospital life, but it does have moments that I really recognise. Bricking it at your first cardiac arrest call, trying to make a relationship work despite the demands of the job, the frustration you feel at the patients who just won’t help themselves as well as those who you feel you’ve made a real difference to are all shown at various points.

I realise this is rapidly turning into an advert, so I’ll stop. Anyway, the DVD is calling, I’m half way through series 7 now, so I guess my normal blogging will resume shortly.

In which I ask for help

One of my old posts keeps getting Japanese spam from a different commentor every time.

Do any of you know how I can stop this happenning without resorting to banning all comments?

Thanks

Fuck the BNP

I’m not usually political on this blog, but the appearance of the BNP’s Nick Griffen on Question Time and the subsequent domination of the media by this fascist’s agenda has me absolutely fuming.

I don’t pay my licence fee for fascists and their followers to come onto political shows on one of the UKs great institutions and spout their hate-filled racist drivel.

Let’s recap some of the BNP’s policies (words in italics are my own comments).

· The forced deportation of 2,000,000 people (or 1 in 30) from the UK. Let’s not forget these will be British passport holders or working here with valid visas. These people will be stripped of their assets including homes and cars on the basis of skin colour.
· Millions of other Brits “of foreign descent” will be “encouraged” to return to their “country of origin.” Exactly what form this “encouragement” will take, I can only shudder to think.

I could keep going with a whole list of thing that these evil fuckers want to do, but I won’t because this post will get too long and I think you get the point already.

And yet, we have so many people who think that the BNP should be given a voice. I had to walk out of the ICU coffee room on Friday because I was so mad with one of the consultants who thought it was right that the BNP should be on Question Time. Fellow bloggers such as The Jobbing Doctor think it’s OK for people to say stuff like “Islam is wicked,” and “There’s no such thing as a Black Englishman” on national television. People who defend the BNP’s right to hate speech seem to have no regard for the targets of the BNP’s vitriol. They have no regard for their fellow citizens, instead they prefer to stand behind the right of the racists even though the very things the racists are saying would deny rights to some of their fellow countrymen based on skin colour.

Why do people in the country find it so hard to say “No.”?

What happened to the British backbone? Why can’t we stand up to these evil people and say, “This is WRONG. You are WRONG. What you are saying is WRONG and we shall have no part of it.”?

This whole episode is deeply shaming on us as a nation and a lot of people need to take a good look at themselves and be honest about what their values really are.

Fuck the BNP.

Thinking about this is getting me angry again, so I’m going to leave you with the words of a Mr Richard Reynish whose letter was published in The Guardian on Friday.

"As Britain debates the BNP’s appearance on Question Time, it would be a good idea to learn from developments elsewhere, before it’s too late. Here in Denmark, where I have lived for 30 years, we have witnessed the systemic hijacking of a progressive and tolerant culture by the far right dressed in “respectable” sheep’s clothing. In 10 years, Denmark has been transformed into a country where racism is in the mainstream.

Free speech has protected hate speech, and opponents of censorship have consistently defended the rights of unscrupulous populists and incendiarists. When the media take this line, a very wicked circle is started: the inflammatory accusations of racists become self-fulfilling prophecies, as minorities are increasingly marginalised and excluded. Mainstream political parties, attempting to win back voters from the far right, make an endless series of concessions, attempting in vain to demonstrate understanding of the concerns of voters tempted by simple xenophobic policies. But the far right will always have a more extreme policy, and a new provocative proposal, which keeps them permanently centre stage in the media.

The “debate” about immigration – in reality a platform for populist racism – dominates politics, poisons serious dialogue an guarantees one thing: racist dominance of the media and the political agenda. "

Richard Reynish
Copenhagen, Denmark.

Credit

During a quiet moment yesterday, I was able to make my way down to the doctor’s mess and spend 20 minutes or so with a newspaper and a cup of tea. Flicking through the pages of the a Saturday magazine, I came across an interview with hip hop star Dizzee Rascal.

Who is the biggest hero of the
decade?
“Nurses, doctors and firefighters”

After what seems like years of negative stories about the NHS, it’s nice to hear us being given some credit for once.

Now I Know

I’ve not blogged much lately because my current job is really hardcore and I haven’t had that much time and I didn’t want to spend the free time I have had blogging because it reminds me of work.

In August, when I started working in Intensive Care the lead consultant, Dr. Cullen, asked me whether or not I wanted to do Intensive Care as a future career. At the time I really had no idea, and told him as much. You see, to us anaesthetists, Intensive Care work is a bit like Marmite in that it we either love it or hate it.

I worked in ICU in my first year of anaesthetic training, but at that time, I felt I didn’t really get a feeling of whether it would be something I’d like to pursue further down the line. I felt that I didn’t know enough stuff to be really useful and I didn’t know enough to actually make a real difference to the patients that I was helping to look after.

I’m now coming to the end of my current attachment in ICU and yesterday Dr. Cullen asked me again if I would consider intensive care as a career. This time I had an answer for him – no.

There are things that I really like about working here, I like it when we’re given a rapidly deteriorating patient, and I can stop their demise and (hopefully) put them on the road towards recovery. I actually like going round the wards and being able to be useful to other doctors who are struggling to look after their ill patients. I like the fact that I can actually do the majority of medical procedures, I’ve done dozens of central lines, arterial lines, intubations, chest drains, difficult venflons etc… etc… and these things no longer hold any mystery or worry for me. I like the fact that the ICU nurses are so switched-on and the fact that there are so many of them means that they can help us doctors out more which means I get to concentrate more on actually trying to get our patients better.

ICU is no land of milk and honey though. There are lots of things I really don’t like. A while ago, I wrote about why doctors get stressed and about some of the ways they cope. I said that simply being around unwell people is uncomfortable for people who have dedicated their lives to trying to make people well. I’m finding this really true of myself. Even when everyone is totally stable and there’s not much happening, I find just being on the intensive care unit stressful. The constant beeps, the almost continual alarms of the infusion pumps, monitors and ventilators, the fact that I know that things can, and often do, go tits up at any moment, all this things conspire to put my blood pressure up.

Our patients are all teetering on the brink of death. Actually, it’s more accurate to say that they’re well past the brink and with our machines we are desperately trying to push them back ONTO the brink so they have a fighting chance of living. This means that one of our patients will frequently drop their oxygen levels or blood pressure to a dangerously low level. They often hallucinate and try to pull out the very tubes that are stopping them dying. While the nurses are very good at sorting these things out, often they’ll need help just to stop the patient from expiring and it’s me that has to go and sort these problems out. Often I feel I’m fighting a pitched battle against the very people I’m meant to be helping. I find it frustrating that I can’t talk to my patients and that they’re often on the ICU for so long with only very tiny improvements to their health each day.

And then there’s the relatives. Seeing your husband/son/mother/grandpa/sister/friend unconscious and hooked up to all our machines must feel horrible. I can’t even imagine how I’d feel if I saw my mother lying their as one of our patients, I shudder at the thought. We try our best to explain what we are doing but I find having these conversations difficult simply because I don’t know what’s going to happen to their loved one. The two commonest questions a relative asks are “Is my loved one getting better?” and “Is my loved one going to die?” And the trouble is, often I simply don’t know if they’re going to live or die and, unlike when I was a physician, often I don’t even have a handle on how likely survival or death is. The uncertainty is often really hard for relatives to understand and deal with. But what I think is even more difficult is the timescale. As I already alluded to, patients stay unconscious with only very slight changes in their condition for days or weeks. We as doctors can see the subtle changes in their inotrope requirement, ventilatory demands etc… but basically, from the outside they look exactly the same. (Actually, as time passes, ICU patients look aesthetically worse as they swell up with fluid and accumulate puncture scars from all the tubes we keep sticking into them.) While we try to explain what’s happening, the seeming lack of progress after such long periods of time is often really distressing because relatives are sort of suspended in a seemingly unending, hellish limbo. Seeing relatives upset in turn upsets me because I too want their loved one to get better quickly, but it’s rarely possible and it leaves me wishing I could do more when I just can’t.

Dealing with other doctors can be wearing as well. There’s a constant trickle of calls for little things like venflons, lumbar punctures, central lines etc…from acopic ward doctors but that stuff doesn’t really bother me. I use my discretion. I help out if the request is reasonable and I’m free and able, if they’re just taking the piss and trying to get me to do their job for them, I have no qualms about telling them where to go. No, there are two things that really get me. Firstly, some doctors seem to have the belief that every unwell person should be looked after by the intensive care team. This really isn’t the case. Sick patients often don’t need Intensive Care, but they need the ward doctors to pay close attention to their condition and give appropriate treatments and sometimes, it’s hard to get ward doctors to understand this. Secondly, there are the group of patients who have been blatantly mismanaged on the wards and then I get a call to see them and am somehow expected to perform miracles. This frustrates me no end too.

And finally, there are the times where it really does all go wrong. There’s the fast bleeps, there’s the trauma calls and there’s the cardiac arrest calls. On average, I go to two or three of these every shift (my record is eleven). These are the situations where people are literally at (or through) death’s door. Sometimes, there’s not much for me to do at these calls, but sometimes there is. Often they’re just a horrible disaster and often the patient dies, sometimes in a more painful and disgusting way than you ever thought was possible.

So all in all, I’m working hard in Intensive Care, but I’d hate to do this forever. There’s too much drama, too much stress, too much politics, and too much frustration. If I had to do this forever, I think I’d end up worrying myself into an early grave, there are far easier ways of earning a living. I don’t think it’s any coincidence that two weeks ago, I found my first grey hair.

Not everyone is happy

Apparently the pigs are a bit miffed about being blamed for the current pandemic...

Lest we forget

“Respect your elders.” It’s a phrase that just about every living person would have heard at some point during their childhood. The sentiment being that those who are older than us have more experience in the ways of the world and that their advice and opinions have a deeper grounding than us and our peers. In many cultures, this is taken further. Stories of our ancestors and forefathers are passed down from generation to generation with the hope that the young will gain knowledge from those that have gone before.

It seems to me that the modern way in different. We don’t respect our fathers, we don’t respect their experiences, and we don’t respect their knowledge. We don’t overthrow them or castigate them. We simply forget them.

I can point to the Credit Crunch of 2007 and the ensuing worldwide recession as a prime example. It’s not as if recessions or market bubbles are a new phenomenon. It’s not as if the factors leading up to a recession are deeply buried secrets. All the documents, all the policies and legislation from the 1920s and even 1980s are all fully out in the open in the public domain. We could all have read all about it if we wanted to – but we didn’t. We didn’t know the history, we didn’t care about the history, we believed that “That was all yonks ago, things have changed now and that disaster couldn’t possibly happen in the modern era.”

We were wrong. It could happen again and it did happen again.

But that what we modern westerners do, we think often about the present and sometimes about the future, but never about the past. Our fathers have always been dead to us. We simply forget them.

It’s happening again. As you sit reading these words, we are in the midst of a global influenza pandemic. Again, 'flu pandemics are not a new thing. We’ve been through them before. Our fathers died in bygone pandemics and those who survived documented what happened so that future generations could learn. We know how pandemics behave and what’s great about 2009 is that we don’t have to go rummaging around old musty libraries to find out. The information is at our fingertips, merely microseconds away. It’s not even in the dim and distant past. There are thousands of people alive today who lived through the last pandemic.

The pandemic hits in the summertime with a large increase in the number of cases. Attempts to halt the spread of the disease fail for a multitude of reasons but at the height of summer, the number of people with the illness falls as people go off on holiday. When they and their children return in the autumn, the disease comes back with a vengeance killing more and more as autumn rolls into winter. Can you guess what’s happening with the swine flu pandemic now autumn is here and schools have resumed?

I guess that human flu has been around as long as humanity itself and in some ways it’s surprising that in this day and age we have remarkably few weapons at our disposal to fight it. Unlike their antibiotic cousins, anti-viral agents such as oseltamivir (Tamiflu) and zanamivir (Relenza) are actually pretty ineffective at treating the flu so, if we get the disease we pretty much have to rely on our own immune systems to fight the disease. History tells us that for a lot of us, our own immune system won’t be up to the task.

So what can we do about it?

As far as I can see, our medical and political leaders are doing what they can. Trust me, I’m no apologist for Liam Donaldson or Gordon Brown but they have at least tried to get the handwashing message out and the antivirals to the right people. More importantly, they have done the best they can to keep the worried well from swamping GP and hospital services. They’ve tried not to panic the population as a whole but, as I say there’s no decent treatment for flu and there’s not much we can actually do for people with flu apart from try and support them as best we can. It seems to me that our best hope of avoiding the deaths that we’ve seen in previous pandemics lies with a swine flu vaccine.

And yet… and yet…

Speaking to my colleagues, it seems that for a variety of reasons, many won’t be taking the vaccine. Polls among the profession show a similar story. We’ve had UK medical blogger Dr Crippen writing in the national press that the vaccination programme is a load of codswallop and that he certainly won’t be having it. There seems to be an ingrained resistance to this simple public health measure and it seems churlish for us doctors as a profession to expect other people to have the vaccine if we won’t have it ourselves.

Personally, I believe that when the first nurse or junior doctor dies from this disease, it will change the attitude of many of my peers, but it’s a shame that it will actually take the death of a colleague for people to start to pay attention to what the past has told us.

But, like I say, this is the modern way. We only think about the present and we forget the lessons that our fathers try to teach us.

Back to business

After having an amazing holiday in the Balearics with friends, I got back to business again last week. I have to say that my current ITU job is really hard work. I’m working lots of long days and, as you can imagine, I have lots of very sick people to look after. You know those pictures you sometimes see of patients in intensive care where they’re plugged into big machines, loads of pumps and have loads of tubes coming out of all parts of their bodies? Well basically, every single one of my patients looks like that. At first the knowledge that I had to look after these people and somehow try to get them better was really bloody scary for me. Now, nearly two months into my job, it’s still really bloody scary. It seems that ITU is the embodiment of Murphy’s Law in that whatever can go wrong will go wrong.

The thing is, I’m enjoying what I’m doing. I appreciate that I’m getting good experience in looking after the sort of patients that you just don’t get to look after outside a large teaching hospital. Currently, we have patients with head injuries, transplants, complicated haematological malignancies and even (whisper it) swine flu. Trying to keep patients alive when three, four or five of their organ systems have failed certainly taxes the brain. I’ve been spending much of my free time with my nose in textbooks trying to get my head around stuff like diabetes insipidus, alveolar recruitment strategies, chemotherapy regimes for acute promyelocytic leukaemia, oesophageal döppler studies and more about bacteria and fungi than I ever thought was relevant.

Practically speaking, I’m getting really good at the procedures that we do. On average, I put in one or two central or arterial lines each day and now I’m pretty confident of getting them into most people, no matter how fat or coagulopathic they may be. I’ve learned the hard way that intubating critically ill people and putting them on a ventilator is a whole different ball game to doing it to relatively well people before their surgery. I knew that already, but it’s one thing being told about what can happen and quite another seeing it happen in front of you and having to deal with the consequences. (n.b. that particular patient was OK and I’ll blog about it another time).

I’m still not sure whether or not I want critical care to be part of my future career. I’ve blogged before about doctors and stress and I have to say that I still find just physically being on the critical care unit surrounded by all those sick people a stressful experience. Even when they’re all relatively “stable,” bitter experience has taught me that they can (and frequently do) get very sick, very fast. This knowledge means that I’m constantly on edge whenever I’m working. Perhaps this feeling will go away as I get more experienced, but perhaps it won’t and I’ll end up worrying myself into an early grave. Who knows? Also, from what I see, there is an awful lot of politics involved in running an intensive care unit and I’m not sure I could be arsed with all of that.

All in all, I’m working really hard and I’m enjoying it at the moment, although I’m not sure I could keep doing this forever.

The NHS in the media

For a while now, there’s been something that’s been baffling me about NHS stories in the media. People I meet think that the NHS is awful and slag it off and it routinely gets a pasting in the media about how bad it is and about how low the standards of care are etc… etc… On the front page of today’s Telegraph, they were at it again.

'Cruel and neglectful' care of one million NHS patients exposed
One million NHS patients have been the victims of appalling care in hospitals across
Britain, according to a major report released today

However, this doesn’t tally with my experience from the “inside.” Just about every single day, my patients and their relatives thank me and tell me I’m doing a good job. I have a growing collection of thank-you letters from patients and their relatives. The vast majority of patients on the ward seem very happy and very grateful for the care that they are getting. This isn’t just my experience either.

The Care Quality Commission’s patient survey says that 93% of patients thought that their care was “good” or “excellent” and just 2% though it was poor. Put another way, a massive 98% or out patients were satisfied with their treatment. What other organisation, public or private, can boast 98% satisfaction from it’s customers? Your bank? Your electricity company? Your plumber? Your mechanic? Your restaurant? Your hairdresser?

When the Yellow Pages found that a mere 84% of its customers were satisfied, they used it to front a huge advertising campaign. When you put it into context and realise that hospitals do far more difficult and complex things than say a builder or and water company, you start to realise that the NHS is truly amazing. Admittedly, it’s not perfect. 2% is 2% too much and there are definitely improvements still to be made, but, looking at the big picture, it’s pretty damn good.

So why do the media keep running these stories that say the opposite? Why have The Patients Association come out with this “report” of theirs?

I’ve done a little investigating and it’s been very revealing indeed. A look at the list of The Patients Association’s backers proves very interesting.

BMI Healthcare. MediRest. Cardinal Health, The Harley Medical Group, Virgin Healthcare etc… etc… Basically, it's a list of private healthcare companies and pharmaceutical companies.

Now, I’m not saying that The Patients Association is merely a front for private healthcare companies. Nor am I saying that private healthcare companies are using The Patients Association as their mouthpiece to the media in order to slag off the NHS. All I’m saying is now I know where these anti-NHS stories are really coming from, and why the media do not reflect the experience of the overwhelming majority of our patients.

Finding my groove

After nearly two weeks at my new hospital, I’m starting to bed down a bit and find my groove now. I’m working as an intensive care registrar and, as you can probably imagine, the responsibility that my new job involves is huge. Out of hours, I am effectively the most senior person in charge of looking after the sickest people in the hospital, which effectively means that responsibility for the lives of the sickest people in the whole city rests on my shoulders.

On my first day, one of the consultants walked all the new doctors around the intensive care unit (ICU) in order to give us a bit of a flavour of the sort of patients we’ll have to look after. At first, I was just a bit overwhelmed by the sheer size of the ICU. There are about 40 or so critical care beds and the variety of illnesses that the patients have is also huge. There are the usual patients with sepsis, multi-organ failure etc, but there are also patients who are post-transplant surgery, and there are those with head injuries, conditions I’d never looked after before.

Starting a new job is always daunting, but I think I’ve settled into it surprisingly quickly. For the first few days, my main emotion was “Oh shit, I don’t know what to do,” but I’m getting over that. I’m realising that actually, the majority of the time, I do know what to do and on the occasions when I genuinely have no idea, there are always people around who can help me out.

As a result, I’m actually starting to enjoy working in intensive care. I admit that I was dubious about it at first, but I’m finding that I like dealing with sick people, I like making an intervention, starting a treatment and seeing people respond to it, and (hopefully) start to get better. It also gives me the feeling that I’m actually being really useful, that I’m able to help out and to make an immediate difference to the patients. I will confess that once the patients are stabilised on the ICU, I still find the slow progression of their treatment really frustrating, but like all jobs, you have to take the rough with the smooth.

All in all, while the step up from anaesthetic SHO to anaesthetic registrar is undoubtedly a huge one, I think I’m coping with the transition quite well. Maybe, just maybe I was ready for the step after all, despite my previous doubts.

Best of luck!

To all the doctors changing jobs tomorrow, to everyone starting work in a new place with new people, to the FY1s starting for the first time, I wish you all the very best of luck.

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…

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.

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.

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.

Something that made me smile

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

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.