It's oh so quiet...

Something weird is happening today. I’m covering the maternity unit and there’s nothing happening. The only woman on the labour ward has just given birth naturally and there’s nobody else expected in. I’ve literally had nothing to do all day. It’s strange.

Not only is it dead quiet here, I’ve just been over to the main hospital and spoken to the on-call team. Emergency theatres have no cases booked and all the patients on critical care are stable. So the on-call team have very little to do either.

This never happens. It’s spooky. I guess that I’m so used to running around like a rabbit on speed that when things do get really quiet, I start to feel tetchy. I’m going to try my best to enjoy it while it lasts…

I ponder...

Remember this post?

Well, I've now been cited in this article in the Student BMJ. Do you think that this counts as a "publication?" Can I put it on my CV?

The weekend starts here!

Woohoo! It's Friday, I've had a half-day, In a few minutes, I'm going to head off to meet up with FashionGirl and we're going to party all weekend! I'm really excited.

For any of you who think that doctors should behave more responsibly, then I'd like to point you in the direction of The Daily Mash who have written a typically well-researched piece about the government's recommended alcohol limits

Beer and wine enthusiasts across the UK stressed that while three to four units may sound reasonable, it's obviously not going to get you trousered, even if you're a lady.

They are now calling on the government to rethink its guidelines or better still just leave them alone and go and bother fat people instead.

Tom Logan, a trainee solicitor from Northampton, said: "It seems to me that they may have confused a safe daily limit with what I like to call 'lunch'."

Have a great weekend everyone, whatever you have planned!

Anaesthetists "don't like talking to people"

When I was working as a general medical doctor, I had a chat with my consultant at the time about my future career. I had pretty much decided that I wanted to switch specialties and become an anaesthetist, but I still wasn’t sure so I was trying to canvass a few opinions. I remember that we had finished the ward round a bit early and the team were having a coffee before cracking on with the rest of the work. The conversation went a bit like this.

Me: I’m still not really sure about what I want to do later on, but I’m thinking of going into anaesthetics

Consultant: Anaesthetics? Why would you want to do that? Is it because you don’t like talking to people?

Me: Not really, I think it’ll be interesting, it’s hands-on and I like physiology

Consultant: Well, it seems pretty boring if you ask me and most people go into anaesthetics because they don’t like talking to people…

His attitude of “anaesthetists don’t like talking to people because your patients are unconscious” is one that I’ve come across several times.

The thing is – it’s a load of bollocks and the truth is somewhat different. I’m as sociable a person as you’re likely to meet and those who know me would say that, if anything, I talk too much. Regarding my job, yes it’s true that I can’t exactly engage in witty banter once my patient is unconscious, but people forget that I do talk to my patients before giving them their anaesthetic – both in the pre-op visit and once they come down into the anaesthetic room. This talk, is crucially important to what I do, both in terms of reassuring the often very anxious patient, telling them what to expect and getting information so I can plan a safe anaesthetic. I talk to them afterwards in the recovery room and on the wards. If I meet them in an emergency situation e.g. in A&E resus, I talk to them there, I talk to their relatives and friends as well– especially those of the patients on ITU. I talk to my staff colleagues, basically I spend a large part of my working day talking to various people about various aspects of patient care and this sharing of information makes everything much safer.

It also stikes me as odd that the “you don’t like talking to people” claim is never levelled at surgeons, after all, they don’t talk to their patients when they’re operating do they? You’ve also got to remember that the conversations I had with patients as a medical SHO weren’t exactly the most scintillating conversations either. They usually revolved around how far the patient could walk, what colour sputum they were coughing up at the time or what their toilet habits were like. I have to say, I don’t miss the conversations that my former consultants were used to having with their patients.

When things start to go tits-up, as can happen very quickly in anaesthetics, talking is crucial to keeping the patient safe. I’ll you an example. I’ve got to anaesthetise a lady with vaginal bleeding so the surgeons can have a look at what’s causing it and try to stop it. From start to end I talked to:

The Obstetrics & Gynaecology (O&G) reg: to find out what he thought was really going on and how long he expected the operation to take.
The patient: extensively, in my pre-op visit to find out about her health and to let her know about the anaesthetic
The Operating Department Practitioner (ODP): to tell her my anaesthetic plan
The theatre team: to let them know that everyone is ready and we can get the patient down to theatre
The patient, ODP and ward nurse: in the anaesthetic room before induction
The ODP and theatre team: to lead the transfer of thee now unconscious patient from the anaesthetic room to the operating table
The ODP: as I stabilise her blood pressure during the rocky first few minutes of anaesthesia
The O&G reg: to let him know that he can start the surgery
The O&G reg: to ask what’s going on as this is taking much longer than the “five minutes he said it would
The ODP: to ask him to help me get another, large-bore drip into this lady and set up a colloid infusion via a pressure bag
The O&G reg again: to ask him to tell me what the hell is going on because this woman keeps tanking her blood pressure to 50/20, forcing me to use inotropes, something I wasn’t expecting to need on this 43 year old woman. He tells me she won’t stop bleeding.
The theatre runner: to ask her to call my reg and ask him to come help me out
The ODP: to prepare to intubate this woman
The anaesthetic reg: to explain what’s going on so far
The theatre runner: to ask her to ask blood bank to cross match us some blood
The ODP: to get some “flying squad” O negative blood and set up the blood warmer
The O&G reg: to get an update on what’s going on – he’s calling his consultant.
Blood bank: to ask how long the cross matched blood will be
The theatre runner: to ask the anaesthetic consultant to attend
The O&G reg and consultant, the anaesthetic reg and consultant: to discuss the problem (D.I.C.) and decide which drugs and blood products we need to give
The haematology consultant: for coagulation advice
Blood bank: to order FFP, get an update on the cross-match and let him know we are sending an urgent sample down.
The whole the team: as we work to stabilise this woman
The ITU charge nurse: to let her know that we’re going to admit this patient to critical care and request that they get a bed ready
The O&G consultant and anaesthetic consultant: as the bleeding eventually stops, we discuss her further care
The theatre team: as we end the operation and transfer the patient to Intesive Care Unit (ICU)
The ICU charge nurse and staff nurse: I explain the events so far and the plan going forward as we settle her on the ventilator
The ICU charge nurse: as a put in an arterial line
The patient’s husband: he’s already been spoken with by the O&G consultant and ICU charge nurse, but I answer a couple of further questions that he has.
The patient: after we’ve woken her up, I explain the events and how she ended up on the critical care unit following her “quick, five-minute operation.”

My point in all of this is just to say that, contrary to what some believe, anaesthetist don’t hate talking to people. It’s good to talk and, every now and then, talking saves lives.

This made me laugh out loud

I had a proper laugh at this one. I used Typealyzer to see what type of personality this blog has and it came up with this:

The entertaining and friendly type. They are especially attuned to pleasure and
beauty and like to fill their surroundings with soft fabrics, bright colors and
sweet smells. They live in the present moment and don´t like to plan ahead -
they are always in risk of exhausting themselves. The enjoy work that makes them
able to help other people in a concrete and visible way. They tend to avoid
conflicts and rarely initiate confrontation - qualities that can make it hard
for them in management positions.

I especially like the part about filling my surroundings with soft fabrics, bright colours and sweet smells. A few hours ago, I was sat in a grey and green operating theatre as the surgeon literally sucked poo out of the patient's bowel. I think this test is just a tad wide of the mark!

The Logbook Blues

As an anaesthetist in training, I’m supposed to keep a record of all the patients I give an anaesthetic to. I’m meant to record their age, their physical state, what type of anaesthesia they had, what operation they were having and whether or not I did any additional procedures. This is so my trainers and I can have an idea of what I’m doing and get some handle on how my training is progressing.

The Royal College of Anaesthetist has helpfully produced an electronic database so we can all record (and encrypt) this data. The idea being that at the end of each working day, I come home and enter the data into my electronic logbook.

The problem is, that this is really tedious and I’m a bit lazy, so after a long day’s work, I can almost inevitably find something better to do than update my logbook. The days and weeks roll on and then I have the sudden realisation that I’ve not updated my logbook for several months. I realise that I have SEVERAL HUNDRED operations to enter into my logbook and there’s nothing for it apart from rolling up my sleeves and sitting in front of my computer and typing in all the information into the database. This literally takes days. It’s so depressing and tedious. This is what I spent much of the weekend doing and I still haven’t caught up. It’s really given me the logbook blues.

Every time I have to do it, when I finally get up-to-date, I promise myself that I’ll never do it again and that it’s much easier to spend 20 minutes doing it every day than spending three days doing it every few months.

And then the next day comes and guess what? Suddenly there are several things to do that are more interesting than updating my logbook…

How to be a surgeon

Anyone can have a go, see how well you fare...

Playing a part

So, I’m on nights again and it’s 4am, when we get the obligatory call from the labour ward. Why is it that labour ward always call at four in the morning? You can pretty much set you watch by it.
The reg and I have had to call in our consultant to help deal with one of those middle-of-the-night dramas that we docs worry about and I take the call from the labour ward.

“One of our ladies would like an epidural, could you come over and do it for her?” comes the voice of the midwife. I tell her that things are kicking off in theatres, but one of us will be over shortly.

“Do you want to go and do it, while I take this patient to ITU?” the reg asks me.
“Sure,” I reply
“Just give me a call if you need a hand.”

I trek across to the maternity unit and make my way to the labour ward and Emily, one of the midwives, greets me as I walk in.

“Hello there,” says Emily.
“Good morning,” I reply
“It’s this lady here,” she tells me as she gesticulates at the board. “It’s her first baby, and I’ve just examined her. She’s 8cm dilated, but she seems to be stuck there.”
“OK, fine,” I say. “Big girl?”
“No, not really.”
“Sensible girl?”
“She seems to be.”
“OK, I’ll go say hello. Hannah’s her name yeah?”
Emily nods at me and we make our way to the room where Hannah is in labour.

A lot is made about the “art of medicine,” and I totally agree that often, practicing medicine is much more of an art than a science. The relationship between doctors and patients is a real example of how much this is the case. Sometimes, I find myself almost acting out a part when I see patients and I’ve learned to play several parts quite well. I can do “chin-scratchingly knowlegable” (with or without actual beard), I can do “gentle and reassuring,” I can do “jokey banter,” I can do “serious,” “stern,” “grumpy,” “dizzy” or “cross.” And I think I can do all of them pretty convincingly. Which of these “hats” I decide to wear with any particular patient depends on the situation.

Generally, labouring women in the middle of the night, don’t want me to sit down with them and discuss their thoughts and feelings about the role of pain in childbirth, they just want something – anything to take the pain away.

I decide that I’m going to be “cheerful and chatty” and I breeze into the room where Hannah and her husband are waiting.

“Good morning! Hannah is it?”
Hannah, looks up at me, briefly stops sucking the Entonox (aka “gas & air”) and croaks a weak, “yes.”
“My name is Dr Michael Anderson, I’m one of the anaesthetic doctors and I’ve been asked to come and see you because you would like an epidural, is that right?” She nods, “Have you read about epidurals?” She nods again, “Good, well there’s just a couple of things I’d like to re-iterate…”

And I go off on my “epidural spiel.” I then ask her a few questions about her health and the pregnancy, scrub up and get started.

As I’m getting the kit ready, I talk to her about herself, whether she’s excited about actually having her first child, baby names etc… etc… As Emily manoeuvres Hannah into the sitting position, Hannah asks me.

“Could you talk me through everything that you are doing?”

This poses a bit of a problem. When you explain any skill to someone else, be it epidural insertion, making a football swerve, cookery, you want what you are doing to go perfectly otherwise you look like a bit of a tit, or in this case, incompetent. You don’t know how things are going to go until you actually do them. Never-the-less, I don’t envisage that I won’t be able to get the epidural into Hannah, so I say “sure thing.”

“Right Hannah, you’re going to feel some really cold liquid on your back now, this is the alcohol prep we use to kill any bugs that are on your skin… OK, now here’s a sticky drape that I’m just going to put on your back… What I’ve got now is some local anaesthetic. What this does is numb this area of your back. It stings a bit when it goes in, I’m afraid, but the stinging will ease in about ten seconds or so…”

“I’ve got a contraction!!”

“OK Hannah, use your gas and I’ll wait. Just let me know when the contraction has passed.”

“OOOOHHH!!!, AAAARGH!!!!” comes her reply, as another contraction takes full hold. Hannah certainly has a good set of lungs on her, but it gives me a good guide as to when to wait. Basically, if she’s not screaming, I’m OK to carry on.

Her cries die down so I say, “has that passed now?” She nods. “OK, I’ll carry on. I need you so curl right up as much as you can now. Put your chin on your chest and really slouch those shoulders down.” She complies. “What I have here is the epidural needle, you’ll feel some prodding and pressure, but you shouldn’t feel any sharp pain. If you start to feel pain in your back, just let me know and I’ll put some more local anaesthetic in… What I’m doing now is looking for the right spot in your back, the spot I’m looking for is cunningly called the epidural space and if you can imagine, it’s about half a centimetre squared and it’s about five centimetres deep into your back…” I feel the give on the syringe I’m holding as my ‘loss-of-resistance technique’ tells me that I’ve found the epidural space – probably. “And there it is… I’ve found the right space, so I’m going to put the plastic tube in now… You may feel funny tingling sensations in you bottom or your legs as this goes in…”

Hannah gives a little jump, “Oooh! I really can!”

“People often feel twinges,” I go on. “Now, I just need to do a couple of tests to make sire that this is in the right place, before we can use this, I need to know that the plastic tube hasn’t gone into your spinal fluid or into a vein…” I look down at the epidural catheter, but already, I can see that the tubing is filling up with blood.

Bollocks. I’m going to have to take it out and do it again.

“I’ve got another contractiioonn AAARGGHH!!!!” shrieks Hannah.

As her contraction reaches its crescendo, I ponder if I should attempt to move the epidural catheter and try to wiggle it out of the vein or take it out completely and try again. On balance, I feel it’s safer to remove it.

“It’s passed…” gasps Hannah

“Ok,” I reply. “This epidural isn’t in quite the right place, I’m going to have to take it out and put in another, try and keep as still as you can for me.” I ask Emily for another epidural pack.

The second time, it goes in fine. I satisfy myself that I’m happy with its position.

“Now, Hannah, I think it’s in the right place now, so I’m going to give you a test-dose of the painkilling mixture.” I check the bupivicaine/fentanyl mix with Emily and give a small dose into Hannah’s new epidural. “OK, that seems to be going in fine. We need to stick this in now, after all this – we don’t want the epidural falling out do we?”

We stick down the epidural and ask Hannah to lie back down on her back.

“Can you lift up your legs for me?” I ask. She can. “Do you feel any different?” Hannah scrunches up her face at me. “Be honest,” I urge.

“I can’t say I do really,” she tells me.
“You’re not meant to,” I say. Now I’m going to give you a proper dose.” I say as I squirt the epidural mix in. “Does it feel cold in your back?” She nods at me. “Like I said earlier, it’ll take about 20 minutes or so to work and in that time, Emily will be checking your blood pressure. But after that, the pain will be much more bearable. I’ll go and do my paperwork, but I’ll come back in a few minutes.”

“Thank-you.”
“You’re welcome.”

When I wander back in ten minutes later, Hannah beams at me. “It’s working?” I enquire.
“Yes, it’s working! Thank you sooo much!!”
“You’re very welcome. Later on today, after you’re baby’s been born, someone from the anaesthetic team will come and see you to make sure that things are OK. But I’m going to leave you alone now, I wish you all the best and congratulations in advance for the new baby.”
“Thank-you” says Hannah again. I leave her room, thank Emily for her assistance and walk back to ITU feeling very proud of myself.

"You can learn a lot by reading newspapers"

“Why do you read newspapers Daddy, they’re so booooring,” I asked as a seven-year-old, one Sunday morning.
“Because you can learn a lot by reading newspapers,” my father replied without looking up from the broadsheet.
“But it’s so boooring!”
He fixes me with a look. “It’s not boring, son. It’s important to keep up to date with current affairs and what’s going on in the world”
“But why? Can we go to the park?”
“If you’re good, we might go the park later”
“Yay!” I whoop and run off to put on a Road Runner cartoon that we’d recorded on VHS.

My father, of course was right. You can learn a lot by reading newspapers. As boring as they were to a seven-year-old me, I can assure you they’re nowhere near as boring as watching a surgeon operate. So, I’m sitting in theatre, reading a newspaper and doing my best impression of the clichéd anaesthetist, when I come across this article. Now, it’s not often I learn something genuinely new and relevant to my work in the press, but this was the exception. Of course, I’d heard about this survey, but I wasn’t aware that the results had been published. It made interesting, and reassuring reading. Later on, I found out that this news had made the press here and here as well.

As a medical student, one of the doctors on the firm I was attached to took the piss once because of something I’d said. “Do you learn all your medicine in the newspapers?” he asked me. I wanted to check that I hadn’t somehow missed the boat entirely with this and was reassured that the results of the survey had indeed only been released the same day.

To be honest, the results haven’t really come as a surprise to me at all. As a doctor, indeed, as a human, I see the risk through the lens of my own experience. I’ve been studying and practicing medicine for many years now and I’ve seen first hand what happens when things go wrong. I’ve seen first-hand, the complications of things that doctors do.

I’ve seen renal failure caused by diuretics and deafness caused by antibiotics. I’ve seen chest infections and would infections, deep vein thromboses and pulmonary emboli after surgery. I’ve seen a tension pneumothorax caused by a central line and I’ve seen a man have a brain haemorrhage after being given thrombolysis. I’ve seen what can go wrong with anticoagulants and what can happen if a surgeon puts a stitch in the wrong place.

I’ve seen all of this, and much, much more.

I have never seen a patient come to serious harm because of an epidural or spinal anaesthetic.

The 3rd National Audit Project of the Royal College of Anaesthetists backs up my own personal experience with some hard facts. Like I say, this is very reassuring news indeed and my father was right, you can learn a lot by reading the newspapers.

In the event of a fire...

One of the things that we were told on induction day was what the fire alarms meant. Fire safety in hospitals is second to none, and not really a day-to-day concern for people working within the hospital. Fires in hospitals are so rare that when they do happen, they tend to make the news. I’ve never been in a hospital when a fire has started and, judging by the words of a man who has, hope I never will be.

On that first day, they told us that an intermittent alarm means that there is potentially a fire in an area of the hospital adjacent to where you are. Hospitals have big, strong fire doors, so this alarm shouldn’t cause too much concern. On the other hand, a continuous alarm means there’s potentially a fire in the area in which you are in, and these should be taken much more seriously.

On Friday afternoon, the fire alarm went off. A very loud, continuous alarm sounded right outside the theatre we were operating in. What can you do? The surgeon and I looked at each other and shrugged and carried on the operation. As the alarm continued, it occurred to me that if there really was a fire nearby, it probably wasn’t the best idea to sit right next to a machine receiving 100% oxygen compressed to four times atmospheric pressure.

In the end, nothing exciting happened as it turned out to be a false alarm. The firemen turned up (which a couple of the nurses found very exciting) and peace was restored. The incident did make me think long and hard about what exactly would I have done if the theatre had started filling up with smoke…

In the best interests of our patients

A while ago, I read a book called “More Sex Is Safer Sex” by Steven Landsburg. The book is not actually as exciting as its title suggests, as its main thrust (pardon the pun) is about economics and the cost of externalities, a subject I was particularly interested in at the time. The book itself isn’t particularly good, there's lots of sloppy thinking and Mr Landsburg has an annoying habit of presenting opinion and speculation as hard fact, but there is something in that book that I’ve really taken on board.

It’s basically that, with every political decision that’s made, there are winners and losers and it’s often not about the money at all. If a council approves the building of a new road, who really gains from that decision? Who loses out? It’s important to bear this in mind when you hear about a particular decision being made by politicians, or by anybody else in power.

I’ve taken this to heart and I always try to work out who really benefits from various political decisions.

Have a read of this and decide for yourselves. Who is really benefiting from this? Who is really losing out?

NHS Foundation Trust

I like to think that I take an interest in the machinations of the hospital and I try to have a broader idea of what’s going on, but I received a letter last week that has me puzzled.

You see, my hospital is trying to get “Foundation Trust Status” and I received a letter from the-powers-that-be asking if I wanted to “opt out of being a foundation trust member.” I assume that they have to ask all their staff this question as a legal requirement because everyone in the hospital has received the same letter.

The thing is, I have no idea what being a “Foundation Trust” means. I have no idea what difference it would make to what I or any of my colleagues do on a day-to-day basis. Funnily enough, nobody else seems to know either. Not my junior doctor colleagues, not the consultant, the nurses. To be fair to the management, they sent us all a nice leaflet which I think was meant to explain what foundation trust is. It had lots of pictures of smiling people and lots of nice phrases like “delivering first-class healthcare,” “communicating with staff,” and “engaging with the community” but isn’t this what we are doing anyway? Nowhere did it say how things are going to be different if we get Foundation Trust Status.

I thought I’d try and dig a bit deeper so I collared the theatre manager and asked his what difference Foundation Trust Status would make.

He breezily tells me that “it lets the hospital have more control over how we spend money.”

“So how would that change what I do in my job?”

He didn’t have an answer for me.

Some of the nurses are more cynical about the whole exercise and told me that “it basically means that they can re-band our jobs and pay us less,” but I don’t know if this is true either.

I’m still none the wiser about what Foundation Trust Status means and it doesn’t look like anyone’s going to tell me.

It seems strange to me that becoming a Foundation Trust is obviously a big priority for the people running the hospital, but none of the staff even know what it means. How can an organisation that employs hundreds of people be successful when the people who are working have no idea what they’re allegedly meant to achieve?

2008 and all that

This post is a few days late as I’ve been too busy enjoying myself. I’m going to wish everybody a belated happy new year and a very healthy, happy and prosperous 2009.

New Year, New Beginnings, but also a time, I feel, to reflect back on the year that’s passed and think about how things have turned out. Have I done everything that I intended to a year ago? Do I think that I am generally happier now than I was twelve months ago? If not, then why? And what am I going to do about it?

I was driving back from my parents’ place the other day and I started to think about the high points and the low points of 2008, and in am award ceremony style, I’m going to tell you about my personal highs and lows of 2008

Inspiration of the year

She’s battling her third different cancer in seven years. She’s lost those close to her but she’s not giving up. Seeing Mrs Campbell slowly pick herself up from her personal low, pull herself through her dark days then slowly get better and eventually leave ITU and then hospital altogether was one of the most inspiring things I’ve ever seen. We all think we’ve got our own personal problems, but they’re nothing compared to what this woman’s been through. When you see someone come through what she’s had to go through, it puts your own life and your own issues firmly in perspective. Stand up and take a bow, Mrs Campbell, you are my inspiration of 2008.

Personal achievement of the year

I’d like to say that passing my FRCA primary exam after only 14 months in the job is my biggest achievement this year but, on reflection, I don't think it actually is. I think that my biggest achievement is that I’m slowly and inexorably becoming a better anaesthetist. In January last year, I couldn’t do half the things I can do now and I feel that as each day passes, I’m getting better and better. Earlier in the year, I had a bit of a crisis of confidence, but that’s passed now, and I feel more determined that ever to try and raise my game and be a great doctor.

Runner up: Passing those bloody exams.

Low point of the year.

Driving home after a shift in which there was a particularly horrific trauma call, I had to pull over to the side of the road because I could no longer see through my own tears. Maybe one day, I’ll post about what happened, but at the moment it still upsets me too much to think about it. This job can sometimes break you right down.

Runner up: MMC 2008-9. Nothing seems to be happening. Nobody’s admitting responsibility for this mess and things HAVE NOT CHANGED. My generation of junior doctors still have no jobs to apply for. The Tooke Report seems to have been deferred until people have forgotten what the fuss was about. The situation on the ground is awful.

Villian of the year

I’m lucky enough to have a great group of friends and to work with people who obviously share the same aim as I – to do the best for our patients however we can. I’ve had the odd disagreement at work, but I’m fortunate enough to have not come across anyone who I would remotely describe as a villain. In the absence of any nominations from my personal life, I’m going to give this award to the evil scum that goes by the name of Robert Mugabe. How many more must die Robert? How many?

Runners up: City Bankers – you guys have a hell of a lot to answer for

People power moment of the year

The reinstatement of Dr Scot Junior after stirling work and public pressure from Dr Rant, Jobbing Doctor, Witch Doctor, Dr Pal among others.

Runner up: Obama’s election

Hero of the year

The bissest prize from me has to go to FashionGirl, my girlfriend. She’s stood by me through some really tough times this year. She was there when I was having some really dark days and she’s been there to celebrate some really good times too. I really admire her in all sorts of ways and think she’s truly fantastic. She’s my hero, without a shadow of a doubt.

Runner up: Dr Harrison

Anyway, those are just the ones I just thought of from the top of my head. How about you? What were your personal highs and lows of last year?

Once again, I wish everybody a very happy 2009!

Mangling Medical Careers

When I started this blog, I deliberately tried to avoid writing about Modernising Medical Careers (MMC) because the whole debacle pissed me off so much and I’d just get really angry whenever I thought about it.

It’s now two years since specialty training and recruitment came under the MMC umbrella, so I thought I’d revisit the subject to see if the powers that be have managed to iron out the problems the new system had at its inception.

One of the key concepts of MMC, the new post-graduate training system for doctors, was to end the “lost generation” of Senior House Officer (SHO) junior doctors who spend far too long in SHO posts and face far too may barriers to career progression.

A quick look at the MMC website shows how beneficial the changes have been to junior doctors. They’ve got rid of the name “SHO” and given us names like CT1, ST2, FTSTA2, ACCS1 etc… etc… but the jobs that we are doing are essentially the same, so I’ll refer to all these posts as “SHO” in this post to try and avoid confusion. All SHOs would like to progress to being a Specialist Registrar (SpR) with the long term aim to complete our training and become a consultant.

MMC has renamed the SpR posts as “ST3”

Now, lets say that you’re a junior doctor and are coming to the end of your two or three years as an SHO and want to move on to an ST3 (SpR) job next year to progress your training. Oh, and lets say that you want to stay roughly where you live at the moment because that’s where your friends and family are.
For the specialty of anaesthetics, let’s see exactly how many jobs there are to apply for in England & Wales in 2009.

East Anglia and the East of England – 1
East Midlands – 2
Kent, Surrey & Sussex – ZERO
Manchester, Lancashire and the North West – ZERO
Newcastle & the north – ZERO
Oxfordshire – ZERO
Cornwall, Devon & Dorset – ZERO
Bristol and the Severn area - 1
Wessex – 1
West Midlands – ZERO
Yorkshire – ZERO

All of Wales - ZERO

In fact, the only places where are any vaguely sensible numbers of jobs are Liverpool and London. If you happen to live anywhere else, you’re going to have to move. In the whole of the country, there is a sum total of 55 jobs available in 2009. My back-of-an-envelope calculations tell me that there’ll be in the region of 350-450 doctors wanting one of these 55 jobs. What happens to the people who don’t get one of these jobs? Nobody knows, and the impression that I get is that nobody really cares. The situation is even worse for doctors who want to be surgeons, paediatricians or physicians.

Remember that the stated aim was to PREVENT barriers to career progression. How can a system that’s been six years in the making fuck things up so badly?

Happy Christmas

I wish you all a very Happy Christmas indeed.

Pink or Blue?

It was a few months after I’d started my anaesthetic training and I was slowly becoming more confident (and competent) about giving general anaesthetics safely. I was going a general surgical list and Dr James was the consultant anaesthetist in charge. Dr James said that she was going to “loosen the reins a little” and told me that I was going to look after this list by myself and that her role that morning was to “drink coffee and administer the occasional bollocking.”

So I got cracking and things were going well. True to her word, Dr James made various cameo appearances throughout the morning and “questioned” my choice of drugs and anaesthetic technique. The last man on the list was a 77yr-old with a few medical problems. Of all the people I had to put under that morning, he was the one I was most concerned about.

Anyway, I get him in the anaesthetic room, do all the per-op checks with the ODP (anaesthetic assistant) and get the monitors on. I put in a drip and set about getting him anaesthetised. I figured that he wouldn’t need much of my induction drug, so I slowly trickled in the propofol.
Despite my caution, things started to go wrong. After he became unconscious, I was able to bag-mask ventilate him OK and I after I put in the LMA, his chest was rising and falling, a sign that I was getting oxygen into his lungs. Despite this, the monitor was showing

O2 sats: 77%

And this is bad.

The ODP was a man called Edward, who was very experienced – in fact I believe he was set to retire in a couple of years’ time. Edward looks at me and says “Sats are low”

“I know,” I reply as I turn to oxygen up to 100%
“Is the LMA in properly?” he asks.
“I reckon so”
“Are you sure, I mean sats are only 75%! Do you want to take it out?”

I really didn’t think that this was an airway/ventilation problem and the fact that the blood pressure cuff was taking an awful long time to give me a reading made me think that the problem was that the patient didn’t have a blood pressure.

“No, leave it in,” I say.
Edward looks at me incredulously. “Well, what do you want to do?” he asks. “Shall I call for Dr James?”
“Yes, please do.”
Edwards kicks open the door to the operating theatre and yells at the theatre nurse to go and get Dr James NOW.

I look at the monitor again, it still says that the sats are 75% and, rather ominously, this mans heart rate had dropped from 70bpm to 45bpm.
“Edward. Squeeze this bag for me” I say and I open the cupboard to get out some emergency drugs. I pause for a second to consider which inotrope to use and at that moment, Dr James bursts into the anaesthetic room.

She looks at the patient then looks at me, then looks at the patient again then looks at me. “What’s going on?!” she exclaims.

“Hypotension… and bradycardia.” I mumble
She bags the patient and asks, “what have you got in your hand?”
“Atropine.”
“Ok, give 300mics”
I do so, and seconds later, the patient is better. Sats read 95% and the blood pressure is back to 133/58.
“How much propofol did you give?” Dr James asks me
I look at the syringe that is sitting on the anaesthetic machine. “105mg altogether”
“That’s not a great amount is it?”
“No, not really. I was actually really surprised that such a small dose had such a massive effect on this man”
Dr James shrugs and says “sometimes it happens like that.”

We get the patient through into the operating theatre and onto the theatre table. Dr James laments, “whenever I get called into the anaesthetic room, my first question is: ‘Pink or blue?’”

“Pink or blue? I’m confused”
“As in; ‘Is the patient pink or blue?’ This man…” she gesticulates at the patient on the operating table “was pink. So I knew things weren’t too bad.”

I mentally raise an eyebrow at this. I’m not sure how bad things have to be before Dr James gets worried.

“You did a good job,” she says and literally pats me on the back. “Carry on…” and with that she saunters back out of the operating room, presumably back to her coffee.

Edward and I look at each other and shrug as the surgeon starts the operation.

Christmas Bonus

My girlfriend got her Christmas Bonus the other week. Because of her hard work and dedication though these difficult economic times, her company has given her £1000 to say thank-you for all that she’s done for them in 2008. What’s more she’s now out dancing the night away at her company’s Christmas party, with free drinks at a venue all paid for by her company as a thank-you to the staff.

I got my Christmas Bonus yesterday. As a reward for all my hard work and dedication over the last year, my company gave me a £1.50 discount voucher for the Christmas Dinner. It meant that only had to pay £3.00! I feel so happy that all the extra (unpaid) hours I put in have been recognised. That I get some recompense for all the occasions that I’ve done extra shifts to cover the gaps in the rota. That my hospital wishes to thank-you for all the unsupervised lists that I did – not because it helps my training, but to cover for absences and make sure that operations don’t get cancelled.

Such is life as a public sector worker.

It’s not all bad though. After I paid my £3.00 for the Christmas Lunch, I got a “free” Christmas cracker – so I can’t complain too much, can I?

Hi! My name is... My name is... My name is...

DrJDR posed me this question in a comment to a post that I made earlier in the week

I wonder what you think about the whole 'first names' question? That is, should
you (the doctor) introduce yourself by your first name - such as 'My name is
James, I'm a forensic psychiatrist'? I remember being told off in an exam for
doing this kind of thing, and since then I've always been very careful not to
use my first name and stick to surname - ie 'my name is Dr Blunt' (well it isn't
really, of course). I think that this does set the professional boundaries very
clearly which I think is important for patients. I used to constantly cringe
when hearing young nursing staff / assistants breezily addressing sick old men
and women on their first meeting by using their first names. I always thought
this inappropriate, and personally I would not like to be called by my first
name by someone I had never met. Professionalism in medicine as a whole is
something which has really suffered, and which I think we need to keep going.
Patients expect us to act in a professional manner, and when we do this gives
them confidence in us.

To be honest, I have no hard and fast rules about which title I use to introduce myself. I’ve used “Michael,” “Dr Anderson” and even “Dr Michael Anderson” depending on what seems most appropriate at the time. I have to say that my “default” when introducing myself to an adult or late adolescent is “Dr Anderson,” but I do vary it – yesterday's post for an example.

When addressing patients, I tend to use their full names to start with and then I’ll use their surnames for the rest of the conversation, unless they tell me otherwise. So, generally, it goes something this:

“Good afternoon, is it Amy King?”
“Yes, it is.”
“Pleased to meet you, my name is Dr Anderson, I’ll be the anaesthetic doctor for your operation later on today. Is it Miss or Mrs King?”
“Mrs, but please call me Amy”

Patients are frequently extremely anxious when I see them pre-operatively and you’re right, that professionalism and good communication are incredibly important.

With children, especially young children, I do tend to use first names more, but again, this is no hard and fast rule, and I'll often use surnames with children as well. It depends on the child.

At the end of the day, part of my aim is to try and make the person I'm talking to feel as comfortable as I can using whichever names I feel fits the situation best. It seems to work pretty well for me, but no doubt there's occasions where I've got it wrong and no doubt, I'll get it wrong in the future, after all, every person is different.

I do call patients “dear” or “my dear” occasionally, (yes, I know we’re not supposed to) but again, I’ll do this only when I feel it’s appropriate and certainly not until I’d built up a relationship with the person that I’m speaking to.

A Sliver of Hope

It's 9pm and I'm on nights once more. There are no emergency operations to do, so I'm in the intensive care unit, helping out as best I can. Bindhu is the registrar on call tonight and is my direct senior for the shift. We’re walking round the unit and she’s giving me a brief handover of all the patients as we do so.

We pause at the end of one of the beds and I recognise the lady in it. It’s Mrs Campbell. Last week, I’d pre-assessed her for her emergency operation and then handed over her care to the anaesthetist on call during the day time. I smile at her and receive a tight grin in return.

"You won't get much out of her," says Bindhu. I give her my best "quizzical" look, so she elaborates. "It's a bit strange. Every time I try to speak to her she won't answer me, or even acknowledge me, but when I watch her with the nurses, she seems to be completely different. Mind you, she's apparently been a bit better today. In the daytime, they made the surgeons come down and explain to her what went on - or should I say, what went wrong - with her operation and explain what they're planning to do about it. I mean, it's only fair isn't it? I don't see why we (anaesthetists) should have to take the flak, when really the cause of her problems is nothing to do with us."

"Indeed." I reply. "I'll bet you that I can make her smile though."

Bindhu throws her head back and gives one of her lilting little laughs. “Good luck with that,” she says and we move on to talk about the next patient.

It’s now 11pm and Bindhu and I have done all the pressing things for all our patients on the intensive care unit. The nurses have just turned down the main lights, so the room is illuminated by soft glows coming from the lamps at each patient's bedside.

I walk up to Mrs Campbell’s bedside.

“Hello. Mrs Campbell,” I say softly. Her eyelids flicker open and she fixes me with a cool stare. “Do you remember me?” I continue.

She rolls her eyes away from me. “No. I don’t remember you,” comes her flat reply. “I don’t remember… anything. For the last few days, I don’t remember anything.”

This doesn’t come as a surprise to me as she’s been in a coma on a ventilator until a couple of days ago, but I suppose I was hoping that she’d at least recognise me from before her operation. I was wrong.

“My name is Michael, I’m one of the anaesthetic doctors and I saw you before you had your third operation. I just wanted to see how you are feeling.”

“How I am feeling? How am I feeling?” she seems to ponder the question for a while, like she’s rolling the thought around her consciousness. “I feel lousy.”

And then there’s The Silence.

I like to think of myself as a pretty chatty, outgoing person who can talk to just about anyone, but every now and then, I find myself at a loss for anything to say at all.

Here I am, late at night standing next to a woman with several tubes coming out of various parts of her body. A woman who’s just come out of a coma and is too weak to even feed herself. I feel that there’s just no way that I can relate her and what she’s had to go through. There’s no way that I can understand how she must be feeling. There’s no way that I can put myself in her position or even begin to imagine what it must feel like. I fear that any words of comfort that I might attempt will sound trite in the face of this lady’s experiences, so I’m left with no words at all – just The Silence.

As The Silence stretches on, it begins to feel more and more uncomfortable. I’m just standing next to her bed saying nothing, feeling stupid, so I’m compelled to try and just say something, anything at all.

“Yeah, I understand that you must feel pretty lousy right now. Am I right in thinking that you’ve been able to have a chat with the surgeons about the operation?”

She sneers at me. “Oh, I know what they’re planning to do tomorrow. And I know what they’ve done.” She looks away from me again and stares in the direction of the far wall, which has silver tinsel draped along it. “They’ve given me a stoma.” She spits out the last word, like it’s a piece of rotten fruit she’d accidentally bitten into.

She looks back at me now and meets my gaze. I realise for the first time just how piercingly blue this lady’s eyes are. She sighs. “My sister had a stoma,” she says, her voice is a mere whisper.

“And you really didn’t want one…”

“I cared for her for years… For years. That’s her picture over there.” She gestures to the photo frame at the side of the observation chart. I go and pick it up and look at the picture.

“What happened to your sister?” I ask.

“She had MS. And cancer. I spent years looking after her, and looking after my mother. We were inseparable, you know? And do you know what’s funny? During all the time I was looking after her, I knew that there was something wrong with me. But I had to be strong, you know? For her. I’m a very determined woman. But I knew there was something wrong. But I never thought I’d end up just like her.”

“I know this is easy for me to say,” I respond, “but you must try and stay positive. You are getting better. I know you must feel awful now, and there’s a long, long way to go, but, hopefully each day you’ll feel stronger and, as you do so, you may be able to look forward to the future. You’ve just got to try and think…”

“That God knows what he’s doing?” she interjects.

“I guess so.”

“Last Christmas was hard…. very hard. My mother died. She kept saying ‘I want to be with my daughter. I want to be with my daughter’ She kept saying it again and again…” Her voice trails off and tears well in her eyes. “And now she is,” she whispers.

“I saw her last night, you know,” continues Mrs Campbell. “My sister. She was stood over there near the door…”

I wait for her to continue, but there are no words coming. Once more The Silence envelops the two of us.

“Yesterday, I didn’t want to live,” she says. “I’ve got nothing left to live for. Yesterday, I really didn’t want to go on. But today… Today I feel better. I’ve got a dog, you see. I have a little dog that loves me, and I love her. So I’ve got to get better haven’t I? For my dog.” She gives a little laugh. “That dog saved my life.”

“That’s something,” I say. “And as you get better, and are able to do more things, then I’m sure things will start to look brighter. I’ll leave you to get some rest now, Mrs Campbell. Sleep well.”

She closes her eyes and I walk away.

My name is...

One of the things that was drummed into me again and again at medical school was the importance of introducing myself to my patients. In every single undergraduate clinical exam and every single postgraduate exam I have every sat, there have been marks allocated for introducing myself to the patient at the start of the interaction.

Personally, I used to think that being told this again and again and again was really tedious. After all, it’s just good manners isn’t it? I always introduce myself when I meet a new person and patients are no exception.

“Mr Smith? Good morning, my name is Michael. I’m one of the anaesthetists, do you mind if I ask you a few questions?”

or

“Mr Smith? Good morning, my name is Dr Anderson. I’m one of the anaesthetists, do you mind if I ask you a few questions?”

When I first started my anaesthetic training just over a year ago, that was how I’d introduce myself to my patients.

When I first started my anaesthetic training just over a year ago, I’d frequently get blank, uncomprehending looks from the person that I was talking to. Sometimes, people would try to be polite, but it soon became obvious that they had no idea who I was or what I was planning to do to them. You see, it became very obvious, very quickly that, generally, people have very little idea what anaesthetists do, so introducing myself as an anaesthetist didn’t shed much light.

Since starting my anaesthetic training, I’ve had some cracking comments about my job – often from people who (I thought) really should know better.

“Oh, I didn’t know you had to be a doctor to be an anaesthetist!” – from one of FashionGirl’s friends

“If you’re an anaesthetist, all you do is give an injection – and that’s it. Well, that’s what happened when I had my operation. Why do you have to train for seven years to learn how to do that?” – from my own mother

“Once the patient is asleep, you guys don’t do anything do you?” – from a surgical FY1 doctor

“But what do you DO?! I don’t understand what you do. NOBODY understands what you do.” – from my former housemate who is a cardiology registrar (he was v drunk at the time).

“So, are you a doctor then?” – from a patient just after a ten-minute discussion about epidurals, invasive lines and HDU after care.

…and it goes on and on and on.

Over the year or so I’ve been doing the job, I’ve noticed that my simple introduction to the patient is starting to sound more like a job description. These days, I’ll say something like:

“Mr Smith? Good morning, my name is Dr Anderson. I’ll be the anaesthetic doctor for your operation later on today. It’s my job to give you your anaesthetic and to look after you while the surgeon is operating. Do you mind if I ask you a few questions?”

It’s a bit wordy, but it seems to set the tone a bit better and I seem to get a few fewer blank looks.