Tuesday, 26 November 2013

The one sandwich to rule them all


I finished up my first rotation as a junior today and thought I should give a bit of an update. The last few weeks have been a bit hectic, as I have had to cover for the breast F1 (who almost forgot to take his annual leave, and took it all at the end) while my SHO was on nights and then recovery. Busy times! Either way, it has been quite an interesting few weeks, where I managed to bleep myself, I got confused over someone as they had changed out of fancy dress, I have some success at the 'sandwich war' and end up making one of my patients cry...

Before that, I would like to comment on the current 'Movember' crop which is going on in my hospital. A number of the juniors have gone for a certain look, which one of my (85) year old patients commented on, asking me why there were so many people "dressed as 70's porn stars" in the hospital... The same lady came in on 31/10 (Halloween) from a nursing home with her carer from the nursing home and her sister, both dressed as witches. I thought it was a bit strange at the time, trying to take blood from this poor old lady as two witches watched on and cackled, but forgot it until a few days ago when two people were trying to talk to me about this patient. I was pretty elusive (patient confidentiality and all) until they asked why I didn't want to talk to them now, as I was much more forthcoming when she was admitted. It was the same two people, but they just looked very different without all of their witch garb on! 

When you are in the hospital, you carry a little black box of evil, which bleeps at you telling you who wants to talk to you (a pager). When you get a bleep, you get a 5 number code to dial, which then lets you call someone at their extension and learn what 'lovely' job they want you to stay extra late to do. Since I started I have wondered how long it will be until I end up receiving a bleep, going to a phone to answer it, but then calling the phone I have just called off (if you follow me - they bleeped me from the phone I answered from). This seemed very unlikely, as you would be in the vicinity, but I am just such an interesting person I like to wonder about fascinating things such as this. Well, this week this happened, I was around the corner, was bleeped then the nurse was rushed off to do something else and I called myself (engaged of course). There is no real reason for me to write it here, so I won't say any more, but it was one of my 'hospital wonderings' at the start...

In pre-op assessment (The last one I did this rotation, and possibly the last one I will ever do, depending on rotations next year and my chosen speciality) I was assessing women coming in for breast surgery. This is almost entirely people with breast cancer who are having the tumour removed, or the entire breast removed, called a mastectomy. One of the women was 70 years old or so, in a wheelchair and from Moldova. She looked like a 'Babushka', and spoke only Moldovan. I tried to use the telephone translation service, but they told me that she was speaking gibberish to them, so I asked her grandson, who was about my age, if he could translate. He readily agreed, but then told me that she was mad and he wouldn't translate what I was saying to her as she wouldn't understand. What then followed was a very difficult pre-op assessment clinic where I tried to get history from the grandson, and examine this lady, while she shouted garbled Moldovan at me and kept flopping her breast out of her top to wave at me (I guess to show me where the cancer was). The only key information I could get from her grandson was that he told me that she "Had experienced clinical death when having eye surgery in the USSR". When I asked what he meant what he meant by clinical death he told me "it means she died, where did you do your training", and refused to say any more. Such a difficult conversation - I am glad I am rotation onto respiratory medicine now, so won't have to try and communicate with them on the ward!

 A little like this, but a little more smiley

Now for the headline piece. The sandwich wars. I big it up because it is a big deal to me, though probably of little to no interest to anyone outside of my hospital. There is a very fought over sandwich in the league of friends shop that everyone in the hospital wants. I normally pack my own lunch, but when I forget/am too sleepy/forget to buy bread, this is the sandwich that I want. There is only one a day, it gets put out at a random time before lunch, and it seems the whole hospital wants it for their own. It doesn't sound anything special, but it tastes like heaven. And I managed to get it! As you join the queue with it, people you have never met before plead to exchange it, it gives you such a sense of power. If I set up a shop selling these sandwiches in the hospital I wonder if I would be rich, but I think the scarcity is what attracts people the most. Like diamonds. If anyone was wondering, the delicious fellow is below:

Never has one sandwich had so much power over so many

Sadly it has been my last day on vascular surgery today. I am in the same hospital for the year (so I can continue fighting for the important things in life like the above) but I am moving onto respiratory medicine from tomorrow for 4 months. I am really going to miss all of my crazy patients. When I was going around to see them and say goodbye this evening one of them, a lady who used to belong to the TA and drive Bedford Mk. 4 Tonne Trucks was crying and had tears pouring down her face when I said goodbye. She is normally very stoic and even though we had to remove one of her legs due to a nasty bone infection, and operate on the foot of the other, I have never seen her upset before. It has been a very touching final day, with the nurses saying lovely things about me, and I hope that my new ward is as nice to me as this one has been!

Monday, 11 November 2013

Poo volcanos, crazy patients and narrow misses


Another long delay between posts, following another long period spent in the hospital. The times where I do a week, a weekend and then another week in the hospital mean I am working 12 days in a row, and I get really tired! This leads to me almost making mistakes - not dangerous patient care mistakes but awkward never-return-to-the-hospital mistakes. One of two of which I will cover below. This has been the weekend following one of those sets, and I have really enjoyed being able to have massive lie ins and do very little. I will post some bullet points below from things which have happened during the last couple of weeks, hopefully making it easier for me to write than having continuous prose. The most 'exciting' of which is my own lovely poo volcano which I will finish with. Make sure you are not eating.

- My consultant was called a 'nasty, spiteful little man' (he is very short) by one of my patients, who is now refusing to see him and has told me that if I bring him to see her again she will write to the board of governors of the hospital as a complaint. As my registrar hasn't been around much lately and my SHO has been on nights, as a result she has been receiving 'F1 lead care'... He is a very straight talking typical surgeon, but I think that her reaction is a little extreme. How am I meant to know if her wound looks as though it needs the types of dressings used changed, or further debridement? It is worth mentioning that on a ward round with my registrar (who is bald) the same patient told me that I had to be nicer to her, or all my hair would fall out and I would end up 'like baldy over there' - cue awkward silence while nurse is in uncontrolled giggles! 

- Talking to the family of one patient who I thought were really racist as they were talking about how 'The Blacks' did things very differently, and how it wasn't really what we were used to in this country. I was on the verge of rebuking them for being so racist and telling them that the nursing staff were all very well trained, and cared a great deal, regardless of the colour of their skin, before I realised that their surname was Black and they were talking about members of their own family. Disaster narrowly averted!

- I influence decision making for one of the first times since I started here. F1 is mostly about chatting with patients, filling in forms and running around the hospital after seniors; you rarely get to decide anything more important than whether to treat a UTI with trimethoprim or nutrofuratoin. This time I was sitting in the 'diabetic foot MDT' where vascular surgeons, orthopedic surgeons, microbiologists and other specialities meet to decide what to do with - you guessed it- patients with diabetic feet who are in the hospital. Usually this involves deciding whether to operate on different people in the hospital, or which antibiotics to use to treat a case of osteomyelitis. This time they were discussing a patient who had a fixed flexion deformity of his knee, meaning it was stuck bent; this meant that his bent leg was developing a pressure ulcer and an infection due to always being pressed into the bed. There is very little point me coming to these meetings, as I have very little to add as an F1, but I have to anyway. This time the surgeons were deciding to perform a below knee amputation on this man for this ulcer and infection, but I chimed in and pointed out that he would still have this flexion deformity in his knee, and it might press the surgical wound onto the bed. "Good point IO, lets do an above knee amputation instead" and he went on to have the operation, and is doing well. I contributed something!

- One of my patients keeps trying to persuade me to get ant farms. He is sure that they will be much better than all the 'boring, plain pictures' that hospitals have on the wards. After all, "they change all the time, and you can bank on the glass if you are bored". I tried pointing out that the ants would, undoubtedly, end up getting out amd "into your food, in your bed, in your stump wound", but he is sure that no-one would mind, as they are only common British ants, found all over the country (though I hastened to point out, not in hospitals!). I would like to point out here, that according to the all-knowing wikipedia "
Often, containing ants inside a formicarium can be a challenge."  I don't think I will be suggesting the idea to the chief exec any time soon!

- As for the poo volcano, one of the patients in the hospital over the weekend had a blocked colostomy, where she had a large fecolith (stone made out of really hard poo) at the entrance blocking any poo from coming out. This patient had been admitted under the GI surgeons, and they had been performing enemas on her stoma twice a day to try and soften up this rock of poo, which was bigger than the entrance to the stoma, and was blocking it. Sadly, over the weekend, this job fell to the on call F1 (me) as they had gone home, and the nurses were not permitted to do it due to the danger of perforating the thin stoma tissue. I had never done an enema before, let alone some dangerous-type of one where there was a risk of perforating the bowel and letting poo inside the abdomen! Regardless, I had to do this over the weekend, and the experience was awful. The patient was lovely, but I am sure you can imagine what the experience was like. I was warned that this was quite a messy task so covered the patient and the bed with opened out adult disposable nappies. Usually there are a special sort of incontinence pad which are very absorbent and are used for messy tasks like this, but the ward seemed to have run out of them, so nappies seemed like the next best thing. I had to work this thin tube (usually used to catheterise patients) down into the stoma with my fingers (and hand) very carefully, trying to get it past the large rock of poo which was about the size of a kiwi fruit. This took some time, and was quite messy work, but nothing like what was about to come. After I had finished forcing my fist into this poor person's stoma to get the catheter around this solid lump of poo, I had to squeeze two 500ml bottles of fluid down the tube, one was an oil used to loosen up the mass, the other a phosphate solution to help make the bowel more mobile and expel this rock. I am not sure if it was this phosphate solution or the fact that I had just squeezed a litre of fluid into this ladies already-overfilled bowel, but as I was squeezing the fluid down into this stoma, the liquid poo that was stored behind the fecolith was blossoming out. As she was lying down it was going everywhere. Fortunately I had covered the patient and bed in these nappies, but it was running all over the place, finding gaps in the nappies and dripping off the bed onto the floor. I cleaned up after this as best I could, but it felt as though that smell followed me around for the rest of the day. Why do some people think medicine is a sexy profession? Don't get me wrong, stomas are not bad in themselves (the daily heil even states that they can be sexy), i was just not at all prepared for this process, having never even done a 'normal' enema before, after a long week running around.

Picture of a stoma from the internet

- The rest of last week was mostly taken up with the emotional version of the poo volcano above. A consultant from another hospital had transferred a patient to ours for a pre-operation work up for a relatively major operation (no beds at his hospital, supposedly . Only this patient was 102, and after she was admitted he refused to talk to me, and relayed to me through his secretary that the patient was now our responsibility as they were in our hospital. He told me that he had OK'd this with one of my consultants, who was out of the country for a month, so that didn't really help. The family were (rightfully) distressed and angry about this, and the patient stayed in hospital for a week before I could get another vascular consultant to see her and decide what to do with her. He decided that the first consultant had been out of line, trying to get her out of his care, and wanted to send her home. Trying to tell this to her family, however, was not easy at all. Her grand-daughter really wanted her to have the operation. I couldn't tell if she secretly wanted something bad to happen, as the consultant had been very clear about the risks of this major operation, but it was a very uphill battle trying to get them out of hospital. I think that because of the very strong beliefs of this family (who were rightfully distressed by this poor treatment), this could be why the original consultant tried to get them into another hospital - so he didn't have to deal with them anymore. Either way; its not fair on the people whose hospital he sent them to, as they then have to deal with explaining that this isn't the correct procedure for her, and definitely not right for the patient and family, who are sent out of their area and into hospital for a week for no good reason at all.