Poo volcanos, crazy patients and narrow misses

Hi,


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.