Friday, 15 August 2014

The good, the bad and the ugly


I am sorry for not posting in some time. There are a number of reasons for this - first and foremost that sadly I am very busy at the moment. Another reason is that I have been reminded of the GMC guidance for doctors a few times over the last few months (the GMC monitors and regulates doctors working in the UK), and this guidance states that (and I quote) "If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name." This guidance can be found here under point 17. The GMC also makes lots of other recommendations such as not revealing any patient identifiable information (I re-iterate that I mix and match, and change patient information so none are identifiable at all).

This is obviously concerning to me as I have worked hard to be working as a doctor, and I enjoy it a lot, and don't want to lose it because I am breaching this guidance. The option of losing my anonymity as per the guidance seems to be an even worse option, as I feel this could impact on patient confidentiality. If people knew where I was working.studying then does that make it easier to identify people I may have seen?

Some thoughts for me to ponder on, while I leave you with some thoughts to ponder on. The great Junior Doctor Switcharound has been and gone, and I am now working as an FY2/SHO/TLA in a large teaching hospital. This whole period seems a little Mad Hatter's Tea Party-esque where all junior staff up and leave their jobs on a Tuesday and start work on Wednesday. You have the evening to move to a different house, and work out what the new job requires. I am sad to be leaving behind my old hospital, I felt as thought I knew most of the people who worked there and whenever it was a tough on call or night shift there would always be a nurse or two on each ward that I knew who would kindly (or not so much as you will find out!) brew me a tea/feed me cake/tell me interesting stories to keep me going! I have now moved to a much larger hospital, so I am sadly expecting it to be a little less friendly, with less of a community feel, but I am hoping to be proved wrong!

The real reason for this post, general natter aside, is to say that I think that key hospital events fall into 3 (or sometimes 4) categories. Good, bad, ugly and occasionally miraculous. I will give some examples from my last month as an FY1/HO that may make interesting reading  

A few weeks before this event, a lady came to our ward who we diagnosed with very advanced breast cancer. My consultant - who is a very straight talking man - advised her and her partner that if they wanted to get married now was the time, as they didn't have much time left to decide. A few weeks later she came back into the hospital getting sicker much more rapidly, but with her wedding planned for a few days time. Sadly she was far too sick and couldn't make the wedding that they had planned. I worked with the hospital chaplain and we organised a wedding in the ward for them. We turned the clinical room into a bridal room for her to prepare, and many of the other patients got involved. A wonderful experience with a bittersweet ending, as she sadly died the next day. Letting the couple share that moment of happiness didn't take any medical skills, but meant the world to them. As Robin Williams' Patch Adams said:

"You treat a disease, you win, you lose. You treat a person, I guarantee you, you'll win, no matter what the outcome."

I was talking to the lovely lady who I mentioned in my previous post with heart failure and she mentioned that she had been getting recurrent abdominal bloating and had lost a bit of weight recently. The consultant had already ordered a CT scan of her chest, and I asked him if it was worthwhile adding a CT of her abdomen to the request to look into this. He said he didn't really think it was, but I did it anyway - and now she has a diagnosis of advanced ovarian cancer. Since I explained this diagnosis to her she seems to have lost a lot of her fight and I had to leave the hospital before she was discharged, though it looked like she was getting worse. The fluid build up in her lungs had been due to the ovarian cancer. I am not sure if she will manage to leave the hospital, and in part I feel like I am deserting her moving hospitals, but I know that is silly.

During one of my on call shifts over the weekend I had worked from 8AM to 6PM without anything to eat due to the never-ending stream of jobs, and the nurses on my normal ward took pity on me and when I arrived to do the jobs they had asked me to do, they instead took me to a side room and fed me tea and a slice of birthday cake! I was famished so I quickly devoured both, spluttering thanks (along with cake crumbs) to the nurses. After I had wolfed it all down, I asked them where the cake had come from - was it one of their birthdays?
No. It turned out that it was a cake which had been given to a 94 year old naturist on our ward who was very sick with hospital acquired pneumonia (more likely than pneumonia caught outside of hospital to be caused by unusual weird and wonderful bugs). [On a side note, this 94 year old wandered the corridors every night, naked after taking her clothes off, and pressed herself to the windows of the nursing station to look at the people inside!]

Not only had the nurses fed me this geriatric-cake, but they had actually seen her blow/slobber our her candles over a few minutes (those lungs weren't too good, due to all the pneumonia). The family had kindly given the nurses half the cake, but the nurses were not too sure how safe this cake was, so had decided to test it on me. These were not even random people I didn't know - they knew me well as I had worked on their ward for a few months. It was all meant to be a joke, but sadly this joke ended up with me eating some super-bacteria-infected-victoria-sponge. Fortunately I didn't get too sick. I felt a little man-flu-ish over the next few days but nothing worse.

A similar incident happened to me over a previous weekend on call - one of the respiratory specialist nurses I knew well from my previous rotation was doing bank work as a ward nurse, and asked me to come in and see something 'urgently' as she was worried about it. It was a very large boil on a man's back, which I dutifully (with gloves on) began to inspect it. Unfortunately after touching it, it started squeezing large amounts of pus out of it, like toothpaste. This was very unexpected, and of course I had to deal with it professionally. I got some gauze and made sure all the pus came out (once I had started I had to finish) while this nurse and the HCA sat their giggling at me. The man thought it was hilarious as well - he must have been in on it. The persecution I suffer while just trying to carry out my house officer duties like re-writing drug charts!

A brief mention at the end for a miraculous event. There was a lovely man on our ward who used to foster children throughout his adult life - he would have different visitors every day who would all call him uncle (calling foster parents mum and dad was discouraged as the kids already had a mum and dad) and come from all over the UK to visit him. He had a number of problems, but while he was on steroids to treat one problem, he ended up with a perforated bowel and systemic sepsis due to the contents leaking into his abdomen. I tried to get the surgeons involved, but they felt that he was far too sick for surgery and said that they couldn't operate. Without an operation to close the leak, he was almost definitely going to die. He was unconscious with a GCS of 3 when I left him on Friday. I considered writing up what would have been the medications used on the Liverpool care pathway (but now are not after it was phased out) but decided that because he was not in pain or suffering I would just write them up 'as needed' rather than as a continuous infusion, which would remove any discomfort but likely hasten the dying process. I left him on intravenous antibiotics to try and control his fevers. When I came back on Monday I was very surprised to find that not only was he still alive, but he was now awake, though still confused. Over the next couple of weeks he improved dramatically to a point where he was medically fit, though still needed rehabilitation to get him back to the independent self he was before he was admitted to the hospital. He was discharged to a smaller, rehabilitation hospital. His perforation must have sealed itself, and the antibiotics done their work on the infection. The ever-reliable wikipedia I linked above for 'perforated bowel' states that "Surgical intervention is nearly always required" - this must have been one of those few cases where luck wins out.

So, 4 categories and more stories than I could possibly write here. I have now moved to working in A&E, so more (non-patient-identifying) stories to come hopefully!

P.S - This is an amazing set of tips from another blog by halfadoc (now 100% doc) for future junior doctors which I had to link, as they are both true and hilarious

Thursday, 12 June 2014

All the small things


I have just come off of a long day's work and thought it was worth sharing an observation based on a couple of patients today.
I have noticed that it seems to be the small things that make patients happy and thankful, rather than the big things that we think matter the most in the medical profession. Take the two patients below.

The first patient is a 35 year old woman who has an aggressive, metastatic cancer. She was in under us a month ago and my consultant hinted to her long term partner that perhaps they could consider getting married due to the poor prognosis. She came back to us this week, much sicker and more poorly, sadly having planned her wedding this week, and having to miss it as she is in hospital, sick. We have been trying to get on top of the infection she has, and the cancer, to give her more time, but this is difficult. We are not sure she will be able to make it out of the hospital, and I have started trying to organise a wedding for her inside the hospital. Since this planning started, she has become a different woman; much brighter, much happier and much more healthy. All of the complex medical procedures and drugs we have been using for her haven't really made much of an impression, but this small idea has made her a different person. Every time I see her she thanks me for the idea of the wedding and the plan, but never thanks the consultant for the chemotherapy or for the complex surgical interventions that have been used. 

The second patient is a lady with heart failure and fluid build up on the lungs. We have been taking all this fluid off, and she can now walk properly due to being able to breath, and her legs not being all swollen all the time. This has made a huge difference to her, but today on the ward round, and yesterday on the ward round, she just wanted to say thanks to me for talking to her and listening to her worries. She is worried about her husband, and how he is coping at home without her, she is worried about her sister and her new diagnosis of cancer, and she is worried about her own heart. On Tuesday I had a sit down and chat with her while taking some bloods for 30 minutes or so, and now every time we see her she wants to thank us for being so kind and listening. Not for all the diuretics which have sorted out her lungs, or the ultrasound which diagnosed the problem. 

The problem I find with medicine is that moments like this; where you can sit down for 30 mins to talk to someone about their worries about their family; or where you can try and sort out a wedding in a hospital, are not usually possible in hospital medicine. I spend most of the time chasing my tail around with far too much to do. I like to think that, if we employed a few more people then we would all have more time to do things like this - things we all want to do.

I feel like I have had a really rewarding day because of these things, not because of the ascitic drains I put in today, or the clever diagnosis of rheumatoid lung I (might) have made, and the patients feel the same. It would be nice to have a system which let us do more of these things, but I will certainly do my best to try and do what makes a difference, clinical or not

Friday, 30 May 2014

Lord Voldemort


Firstly I would like to apologise for my last post. I realise that the title of this blog is 'Internal Optimist' and I also realise that the last post was not very optimistic at all! I had had a pretty rubbish week and it was cathartic to come online and moan about it. Thank you for your support though!

Since then times have been a bit easier - there have been some difficulties - for example the SHO post where I work has been empty because the SHO who is meant to fill it is on maternity leave, and now one of the registrars and one of the consultants from the team has left the hospital to pursue other interests. This has left our team somewhat depleted, and the workload a bit higher than normal. Despite this there are positives (as well as the fact that I am currently on nights for a week so have escaped the increased workload of the day team!) - Anyway this is in danger of becoming another mopey post like the last one, so I will just tell some stories of what I have been up to / some interesting observations.

The last few weeks have been quite emotional. There have been quite a lot of deaths on my ward, which has been quite upsetting. I think this is partially because the gastro ward I now cover has a lot of sick people on it, lots of end stage liver disease and the like, and I also think I have its been very unlucky that recently there have been lots of people who are very sick. One of the most emotional moments with all of this came the day after a patient with decompensated alcoholic liver disease died. He had been in for about a month and I had got to know him and his family very well over this time, as they visited every day. He was requiring regular ascitic drains to keep his abdomen from filling with fluid, and kept fluctuating between being relatively well and acutely sick. Finally, sadly, he died due to 'SBP' - a bacterial infection of the fluid inside his abdomen. The final time I saw him was when he had started spiking temperatures and his markers of infection in his blood were rising. I went to take blood cultures from him and start antibiotic treatment, and explained the situation to him and his wife in a friendly way. We had a few laughs, I went home and when I came back the next day he had died overnight. 
The next day I had to go down to the bereavement office to fill in the death certificate. As I left the office, his family were sitting out there in a group, tearful, waiting for his possessions and the paperwork. His wife, tears streaming down her face, gave me a huge hug and an outpouring of thanks. Thanking me for being so kind, so caring and fun. "he really enjoyed the last month because of you"... It shocked me and I couldn't really think of anything to say other than 'thank you', and 'sorry for your loss', but I spent the rest of the day in a contemplative mood. Death is not something I like at all, but it is something I had been getting more used to, given all the sad things which have been happening in the ward recently. Being exposed to the relatives right afterwards was not something I was used to, and I think it bought home to me a little more that the patient isn't just an isolated person in hospital who you see. They have their entire family, friends, neighbours, children. All of who are heavily affected by the events. It sounds obvious but its not really something that was in my mind before.

To lighten the mood a little, one of our other patients (a Romanian man) came to our ward telling us that he had serious problems with his liver. The story was that he had developed a yellow tint to his skin but without any other symptoms (painless jaundice makes you worry about pancreatic cancer), and his GP had sent his blood for some tests. 2 weeks later he had called his GP, but been told that it routinely took them up to 4 weeks to get the results and report them to him. Not satisfied with this, he took a plane back to romania, got his blood taken privately in a hospital there, got the results printed, then came back to the UK and came into hospital with the results to get treated. I think it is pretty shocking that our system is less efficient than travelling to a different country (one we tend to see as much less developed than our own) to get the results and bring them back with you! Sadly, on further investigation, he did have a pancreatic tumour. Medicine seems to rarely supply happy endings!

A few interesting observations from the hospital:

There seems to be a war of wants between the nurses and doctors, and the bed managers. Bed managers come around every morning telling people to discharge more people, the calls go up that they are not safe to go home, but we need the beds. What are we meant to do? We keep people in hospital until they are safe to go home (doctor/nurse want) but then we have nowhere to put the new patients that come in via A&E (bed manager want). It seems hospitals just don't have enough beds in them. It is a shame that this seems to create opposition between the bed managers and the doctors, rather than letting them work together for an outcome they could both be happy with.

I am not sure if anyone else has noticed, but medical professionals seem to hate the word 'cancer'. We always seem to take about "Breast C.A." or "Bowel C.A" rather than saying 'cancer' or 'malignancy'. It reminds me of Harry Potter where they characters don't want to mention Lord Voldemort, instead mentioning him as "you-know-who" or "he who shall not be named". I am not sure why people say "C.A." instead of cancer (its the same number of syllables) but I agree with Dumbledore - instead of being scared of the name, taking the power from that name is an important part of the fight!