Lest we forget

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

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

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

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

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

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

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

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

So what can we do about it?

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

And yet… and yet…

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

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

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

Back to business

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

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

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

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

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

The NHS in the media

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

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

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

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

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

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

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

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

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

Finding my groove

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

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

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

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

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

Best of luck!

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

Stepping Up

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

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

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

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

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

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

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

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

The European Working Time Directive (again)

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

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

Swine 'Flu

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

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

Swine 'flu

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

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

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

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

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

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

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

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

I’m keeping everything crossed.

It's nice to have an audience

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

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

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

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

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

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

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

I heard it through the grapevine...

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

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

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

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

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

What the consultants are saying:

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

 What the deanery are saying:

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

 What the junior doctors are saying.

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

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

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

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

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

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

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

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

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

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

 All three of them died.

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

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

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

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

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

Caught unaware

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

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

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

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

 “Are you humming for me or to yourself?”

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

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

Anatomy of a day shift

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

 Anatomy of a Day Shift

 08:05

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

 08:10

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

 08:11

 

Chair Dental

Dr McAndrew

Dr Anderson

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

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

 08:50

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

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

I nod the affirmative.

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

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

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

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

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

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

11:30

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

 12:00

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

 12:30

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

 13:00

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

 13:45

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

 14:15

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

 16:30

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

 17:10

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

 Absolutely! See you at half 7

 And then get into my car and drive home.

Respect

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

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

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

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

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

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

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

 “No, a doctor” I say.

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

 “No,” I reply, “an anaesthetist.”

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

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

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

Dear Nurse

Dear Nurse,

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

regards,

Dr M. Anderson

Something that made me smile

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

I should have got it done years ago

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

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

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

“Nice one, I’m almost jealous.”

“You ought to be.”

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

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

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

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

“Oh, you got it in the end.”

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

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

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

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

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

What a way to start the week!

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

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

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

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

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

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

 “That’s not saline is it?”

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

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

Refreshed and recharged

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

Let's see what this week brings.