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