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A few days ago, I gave a general anaesthetic to a young man called Andrew who was having his hernia repaired by the general surgeons. I remember him very well, he was very pleasant and amiable and in the anaesthetic room, he and I chatted for a bit about how long Rafa Benitez was likely to keep his job at Liverpool.
It was a routine operation, and everything went as it should. I went to see him after the operation and he said his was feeling a bit tender, but nothing that a couple of co-codamol tablets couldn’t help with.

The day before yesterday, I logged onto Facebook and I had a message from an “Andrew M” It read:

Thank you for looking after me the other week. I hope you are well

and Andrew M had requested to be my Facebook friend.

I was really touched. It was really nice that he’d taken the time to find out who I was and then written me a thank you message. However, it left me in a bit of a quandary.

Should I accept his friend request or not?

I mulled it over over dinner and then I decided that, pleasant as Andrew M is, I don’t know him. He’s not my “friend” although, I’m sure we could be under different circumstances. And, because I didn’t know him, I didn’t particularly want him looking at pictures of me and my friends or reading what people had been writing about me on my profile.

I clicked “ignore.”

I would have liked to reply to his message with a “Thank-you, I hope you are recovering well” but I knew that if I replied to his message, then the Facebook website would let him see my profile page. I didn’t really want this either, so I clicked “delete.”

Andrew M probably thinks I’m a bit of a fake now and I wish that somehow, I could communicate with him that I was genuinely touched by his message, I just didn’t want him to see the pictures of me from Big Ed’s house party (believe me, they’re not pretty).

What would you have done if you were me?

One thing after another

One of the cornerstones of being a good doctor is being aware of your own limitations and seeking appropriate help as required.

It’s becoming evident to me that since starting on a career in anaesthetics, my job has morphed from “recognising potentially serious conditions and getting help” to BEING the help that people call when things are starting to go tits up (or, more often, when it’s REALLY hitting the fan).

So, today, on the last of my days on call, I’ve been called to help in the treatment of:

A woman in A&E Resus with major trauma who later died on ITU
A woman with severe anaphylaxis who went to ITU and survived and was fine
A woman with a ruptured ectopic pregnancy who survived and was fine
A man who had a cardiac arrest on one of the surgical wards who died
A man with a perforated bowel and multi-organ failure who is holding his own on ITU
Two young people with acute appendicitis who are fine now.

Today has been busy, stressful and I’ve had to be fully focused with one emergency after another, but I did everything that was required of me (and more) and I’ve given my all for the people who needed me.

That said, I’m looking forward to having a few days off to recuperate and to recharge my batteries.

MRI

I've been down to the MRI scanner a few times to help patients and/or the technicians out before and during the scan. Those machines are LOUD and claustraphobic and I can't imagine that having a MRI scan would be in anybody's "Top 10 of things to do this year" list, no matter how neurotic you are.

Every now and then, a patient would come back from the scanner with a slip of paper clipped to their notes saying something like "Patient unable to tolerate scan" or "Patient refused imaging." I'm actually surprised that this didn't happen more frequently.

Surly Girl tells us how much fun it can be:

Giant washing machine thingy? Check. Worrying bed-thing with a knee holder on it? Check. Incipient panic attack? Check. How long will it take? I quavered in Piglet’s voice. Oh, only about twenty minutes, breezed the machine-operator-lady. I was invited to lie down, had my leg immobilised, was given a panic button and some earphones and was shoved into the scanner. Good lord. Because I had to go in up to my chest, the front of the machine was directly in front of my face. Like, an inch away. From a worrying looking slot-thing labelled “Laser Aperture”. Um. Help? Now, although this was better for me than having to go all the way in (a procedure that for me would necessitate sedation, restraints and a scuba tank), it was far from ideal. Far. From. Ideal.

There then followed an endless twenty minutes of staring at the ceiling, trying to keep breathing, and being subjected to the sort of noises that would have confessions from every last inmate of Guantanamo Bay after three minutes. I mean, the noises!! So loud!! Big clangy ones. Horrible headfuck buzzing ones. Weird oh-my-god-what-was-that ones. It was as much as I could do to stop myself blurting “Madeleine McCann has been in my understairs cupboard all along!” in an effort to make them stop.

Lather... Rinse... Repeat...

Wake up… Go to work… Work… Come back from work… Go to bed... Wake up... Go to work... Work… Come back from work... Go to bed... Wake up… Go to work... Work… Come back from work… Go to bed… Wake up… Go to work… Work… Come back from work… Go to bed…

After a while, working 13hr on-call shifts starts to grate…

Dear Medical Students

Dear Medical Students,
I'm not ignoring you, honest. It's just that you always seem to pitch up when I'm covering emergenby theatres and I'm concentrating all I can on keeping the patient 1. alive and 2. asleep. I may be able to give you few factoids or pointers every now and then, but I appreciate that this isn't much use to you when you don't have a good grasp of how anaesthesia affect human physiology. Come back when I'm doing a day case list where the patients are healthy and I'll be able to talk to you more then and teach you about the practical stuff.
I know it's dull/depressing/annoying being asked to stand in the corner and watch when you're not really sure what is going on, but with me, when I'm doing emergencies, that's the way it's got to be. It's nothing personal, it's just that if I let my attention wander away from my patient, bad things can happen.
I hope you understand.

Yours,
Dr Michael Anderson (junior doctor)

Politics

The more time I spend in theatres, the more I become aware of the sheer amount of politics that is going on all around me. In many ways, it’s a very strange environment because there are lots of different factions, each with their own role.

We have (in alphabetical order so no egos get bruised)

The Anaesthetists
The Managers
The Patients
The Surgeons
The Theatre Nurses, ODPs and support staff
The Ward Staff

And then there are lots of other people who you’ll often see down in the theatres such as parents of child patients, radiographers, translators, medical students and nursing students.

The things is, unlike working on a normal ward, I don’t get the impression that anyone is actually in overall charge. I’m pretty sure the surgeons, anaesthetists and managers each think they’re in charge, but none of them are really. All of the aforementioned groups are convinced that they are doing things in the best interests of the patients, but each will have their own perspective. Each has their own agenda and this frequently leads to friction and arguments.

When certain things go wrong, (please note that I’m talking about stuff like time-delays and work distribution rather than direct patient care) then one or more of the factions will start bitching about one or more of the other factions and how they’re “compromising patient care.” It strikes me that no one really sees the big picture. You’d think that the managers would be in the best position to see the “big picture” but the irony is they are they very group who never actually see the patients – and from some of the things they do, this is all too obvious.

Is there a doctor in the house?

I wrote before about the bizarre state that we find ourselves in regarding staffing. Despite the ridiculous shambles of MMC 2007 that left the majority of junior doctors in specialist training either displaced or unemployed, we now find ourselves in a position where there aren’t enough doctors in the hospital to staff a rota.

The situation has now been picked up by Channel 4 and The Telegraph (the BBC, as always remain silent).

Junior doctor jobs are vacant, and trusts up and down the land are having to scrabble around to find emergency locum appointments at the cost of thousands of pounds per week.

The situation is getting worse and worse on almost by the week. Doctors are completing their training and are taking up consultant jobs, taking a break or going to work elsewhere and, because or MMC, NewTown NHS trust is not able to replace them until August.

This means more positions are being left vacant, more pressure is put on the remaining doctors to do the work and the NewTown NHS Trust is having to fork out more and more money to pay for locums to cover the shifts.

To put into perspective how bad things have become, in February 2007 (pre-MMC) there were 12 junior doctors (SHOs) on the anaesthetics rota at NewTown Hospital, today, there are five. Five doctors are doing the work of twelve.

This is obviously unsustainable and in reality, it’s meant that the consultants are doing many of the duties previously done by the juniors. This is good in that the work gets done and our patients don’t suffer delays or poor treatment, but you have to ask; is paying locums and consultants to do the work of junior doctors a sensible use of resources?

I think not.

My colleagues in general medicine and surgery say the situation for them is very similar.

Once again, I’ll say that Liam Donaldson has a hell of a lot to answer for.

Happy St. Valentine's Day

I saw this the other day and it made me smile...

Gossamer Thread

I was speaking to one of the other new anaesthetists the other day and we were discussing how the job was going. She said that we are now in the “danger period” in that we are good enough to be allowed to do things by ourselves and the consultants are happy enough for us to get on with our jobs without having to look over our shoulders the whole time. At the same time, we’re not good enough to be able to cope with every eventuality. The thing about anaesthetics is that when things go bad, they go VERY bad, VERY fast. I think what happened today just highlights this.

I was covering emergencies today and I get a call from one of the surgeons saying they want to operate on a patient from the Intensive Care Unit. When I go and see this woman, I find out that she is very sick indeed. She is in respiratory failure, kidney failure, she has septic shock and has just had a heart attack. The surgeons want to operate because they think her bowel has died.

The poor woman was on death’s door. I spoke with her and she realised that there was a good chance she may never wake up from my anaesthetic and she may die shortly after surgery.

“But what choice do I have doctor?” she rasps at me in a broad Irish accent. “It looks like I’m going to die anyway.”

It never seems to surprise me how some people can face their own mortality in such a calm and accepting manner. I concede that what she says is absolutely true. I give a terse smile and go down to prepare the operating theatres.

There was no way that I was going to anaesthetise this woman by myself. I know my limits. Yes, she’s clinging on to life by a gossamer thread. No, I’m not going to the person who cuts that thread and finally kills her. The ITU consultant, Dr Jones comes down with the patient and supervises me through the anaesthetic and the operation.

Mrs O’Kelly arrives in theatre and we get her on the operating table and I get ready to put her to sleep.

The last time I was in a situation like this, I coped. Things went well, the patient was alert and lucid after my anaesthetic and I went home feeling dead proud of myself.

This time, it was very different.

I’m not going to go into too many details, but Mrs O’Kelly very nearly died in front of me. I couldn’t cope. I could tell she was dying as well. She went from being pink to purple to blue to grey over about thirty seconds. The alarms on my anaesthetic machines were making all kinds of noises that I’d never heard before (and never want to hear again) and, I tried my hardest, I really did, but I couldn’t stop Mrs O’Kelly’s demise.

Dr Jones stepped in and took over and, thank God, she was able to rescue the situation.

I know that, had I been by myself, Mrs O’Kelly would be dead by now and that’s a horrible thought to have.

I love my job, I really do but at times like this I wonder if I’m really cut out for it. I’m not sure I could deal with people nearly dying in front of me every time I go on call. I think the pressure would get to me eventually. One of the theatre nurses once told me, "Michael, you worry too much" and I think he is probably right.

At this stage in my career, I can’t help but feel that sooner or later, somebody is actually going to die and it’ll be all my fault. I really don’t think I could cope with that. I’m not sure I could deal with that feeling.

I don’t think I’m that strong.

New Shoes

When I arrived at NewTown Hospital, I was issued with non-static shoes to wear in the operating theatres. As an anaesthetist, I don't have to stand up for hours and hours at a time, so although they're not being the most comfortable things I've ever slipped my feet into, I have little cause for complaint.

Except for one thing. The shoes have no backs, so they're more like slippers. As you can appreciate, slippers aren't designed for running in, but this is fine because I never have to run anywhere, or do I?

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I was on call yesterday and I was on the phone to one of the surgical doctors when the cardiac arrest pager went off

"Cardiac Arrest, Ward A2. Cardiac Arrest, Ward A2"

I groaned to myself because ward A2 was right at the other side of the bloody hospital. NewTown Hospital is pretty big, so I estimated that I had about a 2 minute run ahead of me.

I quickly hung up on the surgeon and broke into a jog and soon I realised my error. I was wearing the standard-issue theatre shoes. In order to move at any sort of speed whilst preventing them from flying off my feet, I had to do a sort of run that was part lunge, part shuffle and part waddle. To cap it all off, the only scrubs (theatre clothes) available today were size XXL, so I was trying to waddle with one hand gripping my trousers to stop them falling down. I can tell you I was got some strange looks as I passed the canteen.

Luckily, by the time I arrived on ward A2, the medical team had managed to save the patient and my services were not required. As I wandered back down to the operating theatres I made a note to myself to always, always, always wear my own trainers to work when I'm on call

- Michael

Hypocrisy

"Have you seen this?"

Dr Ahmed, my supervising consultant for the day, is waving a copy of today's Times. On the front page, the main headline reads, "NHS closes its doors to foreign doctors"

Now,I don't usually write about political things in my blog but, I'm just going to point out one thing.

The British medical profession encourages foreigners to sit British post-graduate exams. this is so in can pocket thousands of pounds worth of exam fees from each doctor. At the same time as we are taking their money, we are now telling them they can't work here.

Isn't this more than a little hypocritical?

- Michael

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…