Unwell

Ugh, I'm not feeling too great right now. Nothing major, just a common cold but it's made me feel pretty grotty none-the-less.

I'm following the advice I've been giving to family and friends for years now. I'm taking paracetamol regularly, drinking lots of water and taking it easy for a couple of days.

I think this guy knows how I feel...

I'll be bouncing back soon

- Michael

Reason's I don't miss Gen Med #3 - Nurses

Staff Nurse? Staff Nurse? Where are you?

Off trying to do three people's jobs, that's where.

One of the things that I found really difficult as a junior General Medical doctor was the sheer scale of understaffing of the nursing staff. Patients frequently had delays to their treatment and discharge and frequently failed to receive good care because there simply weren't enough nurses to look after them.

I clearly remember one morning, in my first few weeks as a qualified doctor when I walked onto the ward and realised that there were only two qualified nurses on the ward to look after our 30 patients. When one nurse goes on her break or off the ward we had a patient:nurse ration of 30:1, and I sooned learned that staffing at this level was certainly not an uncommon occurrence. It's awful, it's unsafe and it's unfair on everyone, staff and patients alike.

The nurses were understandably stressed and frazzled as they ran around simply trying to keep a track of the dozens of things that were happening on the ward. I felt bad asking them to do things (like give a patient medication) because I knew that they already had a million things to do and it would just add to their workload.

The operating theatres and intensive care unit, where I spend my days now, are certainly very well staffed. Starting work as an anaesthetist was like a breath of fresh air and I think staffing levels are certainly part of the reason I'm enjoying my job so much now.

I'd like to think that things are getting better on the medical wards, but it seems things are just as bad as ever.

- Michael

Username: Password:

In order to access NewTown Hospital’s I.T. systems, I have four different usernames and four different passwords.

One set is for the PAS patient information system which tells me whereabouts in the hospital the patients are, when their clinic appointments are, who their GP is etc…

Another set gives me access to the patient’s Blood Results system.

A third allows me to look at patient’s X-rays and scans and see their reports.

And the final set gives me access to the hospital email which gives me useful information like when the various IT systems will be offline for “essential maintenance.”

The systems make me change the passwords every fortnight or so and I have to confess that I really do find it difficult to keep track of which is my current password for each system.

Maybe I should write them all down and stick them on the side of one of the monitors…

Junior Doctor?

I've just been pondering the title of my blog "The Junior Doctor" and I was thinking to myself; "How junior am I, really"

I've been studying and working in the field of medicine for about a decade now, and I think that's quite a long time. I've worked in each of the acute specialties and have spent countless hours in hospital. I'm sure I've treated and been involved in the care of thousands of patients by now. Each one unique, each with theor own story...

I'm fully aware that I still have bucket-loads to learn, but after a decade in the field, am I really junior anymore?

My job title says I am, but the question is - if I had spent the same amount of time in any other profession (eg teaching, law, nursing, banking) would I still be considered to be junior at my stage?

Answers on a postcard...

Under Pressure...

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

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

“Yes. Why? What’s going on?”

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

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

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

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

Oh shit.

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

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

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

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

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

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

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

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

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

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

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

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“Yes.”

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

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

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

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

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

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

“Not too bad.”

“Do you understand what’s happening?”

He nods.

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

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

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

“What’s his blood pressure?” I ask.

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

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

“No, not really.”

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

“Not that I know of”

“How much do you weigh?”

“Ooh, about eleven and a half stones”

Right. Here comes the maths part.

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

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

It’s time to start the rapid sequence induction

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

“No,”

I press the oxygen mask onto his face.

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

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

One minute has passed.

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

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

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

Two minutes have passed.

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

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

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

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

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

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

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

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

“You can start now”

The hard work was done.

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

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

- Michael.

Heard around the hospital...

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

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One of the ENT surgical registrars ponders MMC:

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

A text message from a friend doing paediatrics:

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

A fellow anaesthetics doctor:

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

SHO in Trauma & Orthopaedics

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

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

A bad experience (part 2)

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

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

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

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

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

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

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

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

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

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

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

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

“Hello there!” I pipe up

“Hello,” she beams back

“How are you feeling?”

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

“No pain? No sickness?”

She shakes her head

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

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

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

“Certainly”

“Do you remember anything about the operation?”

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

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

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

“Really?”

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

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

“No.”

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

“Oh. That sounds awful!”

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

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

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

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

- Michael

Stick

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

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

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

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

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

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

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

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

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

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

Now, how many people can honestly say that?

- Michael

A bad experience

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

She shrugs and grunts at me

“Had better days, yeah?”

“Something like that. I’m really nervous”

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

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

“Not really,” she replies.

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

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

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

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

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

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

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

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

To be continued…

The Tooke Report

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

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

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

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

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

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

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

Stick or Twist? A New Year's Dilemma

Happy 2008 to one and all.

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

Not exactly progress, if you ask me.

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

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

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

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

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

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

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

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

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

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

- Michael

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

Season's Greetings

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

- Michael

Creature of the night

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

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

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

Where have all the doctors gone?

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

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

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

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

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

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

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

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

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

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

Nurses

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

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

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

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

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

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

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

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

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

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

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

The ward-round octopus



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

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

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

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

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

Winter Food

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

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

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

I love winter food.

Saturday Night

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

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

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

“Oh my God! Look at your foot!”

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

“You’re BLEEDING!” he continues.

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

“You should go to hospital!” the man urges

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

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

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

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

Bleep etiquette

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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