Fading away?

Hi,

Sadly my blog posts are becoming so irregular I doubt people check in to look for them anymore! I am still alive and doing well, finishing my first year of speciality A&E training in a few weeks, but I feel I should explain why I barely post anymore.

There are two main reasons, the first is time - I am very busy with work and all the things I want to do trying to have a life outside of work (which is a constant struggle!). I have also been doing my membership examination which are needed to become an A&E registrar. This comes in three parts, I have passed the first part and am sitting the second in a couple of months! Sadly revision is also time consuming.

The other reason I have been very tardy with updating my blog is over worries as to what it can be used for. I started it as a way to vent my feelings and frustrations, back when I was in 3rd year of medical school, and back then it was weekly. It was initially aimed at showing what medical school was like for prospective medical students, and aimed at keeping up the hopes of 1st and 2nd year medical students, keeping them looking forward to the clinical years (which were much more fun). As I progressed it basically ended up documenting my journey through, which will hopefully be helpful for people to look through if they are interested. However, this documentation also comes with risk. 

I initially started blogging anonymously to avoid breaching patient confidentiality, and to enable me to say what I thought without feeling people were going to judge me for it. However, I am very much aware that being online isn't totally anonymous and it is not too difficult to find out who someone actually is, unless they make a real concerted effort to stop that from happening (which I haven't). There have been a number of cases in the media which have been concerning. For example, a doctors own reflective pieces in their portfolio (which are mandatory to progress to the next year) being used against them in court. It is hugely important for medical professionals (and anyone) to reflect on their mistakes and feelings, but this sets a worrying precedent. Worrying for me as I have definitely talked about (or reflected) on things in this blog which do not make me look good. Another case in the media was that of Christian Solomonides who was taken in front of the GMC and suspended for some of the things he wrote on twitter. He did not use his name on twitter, but was easy to track down (he used his initials...) Much of the stuff he said on there was very offensive, but as someone who also works in A&E I can see why he feels so exacerbated with some of the people who come into hospital. I also feel worried that I have also ranted about staff and patients (though more politely) and question whether this is a GMC-type offence. I guess I also worry that if I share some of my more ridiculous stories this is the sort of thing that this blog has the potential of turning into.

I have thought about trying to tone things down, make things more anonymous or shorter, but I don't really think these things deal with my core concerns about blogging as a junior doctor (especially given the current political climate and press hunger to turn on doctors, some of whom own £500,000 houses, and go skiing for holiday). This is a huge shame, as my last 6 months working on acute medicine have been crazy. There is a mismatched classic 'medical old-school' team with some real 'characters' in it,  and the whole job revolves around a crazy book where all the patients details are stored. Given the old-school nature of the consultants there is no chance of this book being upgraded to something a little more digital. Given the fact that all patient information for the whole medical team is in this one tatty book, with no copies, this book is treated as though it is The One Ring. The bearer is all powerful, with people coming from far and wide to look at their wonderful book, and woe betide you if you accidentally lose it in Mount Doom.

I could talk about some of the ridiculous things which have happened over the last 6 months, but given the above, sadly I do not know if it is wise. I will keep the blog online as hopefully the posts from 3 years of medical school and 3 years of junior doctor-ing to date will be useful, and will keep it periodically updated with my progress if anyone is interested. I will keep my eye on how doctors and blogs/new media is dealt with, and perhaps come back properly if the winds are blowing in the right direction.

12 days of Christmas in the ED

Working in A&E brings plenty of different experiences, here is a selection of true stories from the 12 days run up to Christmas.


On the first day of Christmas, the ED gave to me: a cockroach infestation in resus bay 3

On the second day of Christmas, the ED gave to me: a patient with a baseball bat to the face, and the chance to assist in a lateral canthotomy

On the third day of Christmas, the ED gave to me, a psychotic gentleman after losing a loved one in hospital , the questionable choice to bring the body to A&E due to a flooded morgue to help the patient come to terms, and the dire mistake and consequences of bringing the wrong body up to the ED.

On the fourth day of Christmas, the ED gave to me, many giggling nurses, several confusing PA calls, my name changed on the computer system to 'Bieber', and in inability to change it back until three

On the fifth day of Christmas, the ED gave to me: A patient who had been hit by a bike, a swollen and painful hand, an X-ray showing a dislocated trapezium bone, a referral to a surgeon who wasn't sure what the trapezium bone was, and the feeling that the MRCS must be pretty crappy. 

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I am now, as you can tell, struggling, to keep fitting my recent experiences into this ridiculous format, and will just list the rest. This was a terrible idea to try and do this!
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On the sixth day of Christmas, a patient presented having electrocuted himself with an iron, wearing a T-shirt emblazoned with 'what doesn't kill you makes you stronger'. The irony was lost on him. Perhaps he was going to turn into a superhero, with a super power of resisting the power of resisting literary techniques.

The seventh day of Christmas was not a good shift. I was called a 'dirty fingering heterosexual' by a furious patient, a very anxious man presented who thought he had cyanide poisoning from eating a bag of apricot seeds from a health food shop and refused to leave, and a patient snuck into the A&E toilet and cut her wrists, barricading herself inside.

The eighth day of Christmas started of promisingly with the ambulance service bringing in a patient coded as 'shooting/stabbing/penetrating wound', exciting the department to prepare for a trauma call, until it turned out it was a man who had dropped a kitchen knife on his foot.

On the ninth day of Christmas, a patient with dementia was bought in due to pneumonia. We were transferring them from the ambulance trolley onto one of the A&E beds, when the patient started taking a poo. The carer, who had come in from the nursing home, shouted 'catch it' and the nurse managed to grab the stick of stool mid-air out if instinct. With her bare hands. Merry Christmas...

The tenth day of Christmas was more positive, with a patient telling me they had named the pulmonary embolism they had developed after surgery 'Jeremy Hunt' as it was a "potentially fatal clot" and a drag queen attended with mallet finger after getting their fingers stuck together while gluing on their eyelashes.

They eleventh day of Christmas was a day of detective work.  A child presented having eaten berries from the garden of an unknown origin, but the mum had bought in the leaves from the plant (if only I had a botany degree as well, but good ol' google has the answers as always if you look hard enough). There was also the interesting conundrum of a patient presenting in acute alcohol withdrawal which can be very dangerous and even fatal unless the patient continues drinking, but with the added problem that she had been given a bail condition that she couldn't drink any alcohol, due to an assault, and if she did she would go back to prison. 

The twelfth day of Christmas started well, with plenty of gifts to the department of tasty food from the local Jewish ambulance service (Hatzola) and Muslim communities (interestingly we had many more gifts from groups that were not Christian), but then was ruined when I mistook the medical consultant for a patient who had come in with solvent abuse induced hallucinations, and told her that she needed to pull her act together and that we were not going to give her the glue back that we had confiscated... I am going to have to keep my head down until the New Year!

Procedures and nights

Hi,

Sorry for the poor rate of posting - I have been very busy but that is always my excuse. I am now in a training post as an emergency medicine trainee. The hours are pretty rubbish, and I am working every weekend this month, but I love the job. I get to see a complete range of diseases and people every day and get to do a lot of different things.

I am on nights this weekend, but over the last week and this weekend I have seen people ranging from a 45 year old woman with vaginal bleeding 4 weeks following her last period (quickly diagnosed as her next period and discharged) to people in cardiac arrest and with severe burns and explosion injuries following bonfire night mishaps. 

I really like the procedural side of A&E, and the chance to get away from the constant push to see and discharge people before they 'breach' the 4 hour wait and sit in a room for 20 minutes and do some suturing or put a joint or broken bone back in place. Yesterday night (or this morning more accurately) someone came in with eye pain for 3 days following angle grinding some metal without eye protection. I am not an expert with the equipment needed to examine eyes (called the slit lamp, and often seen at opticians) but I could see a small piece of metal just over the iris (similar to the picture below)

Metal piece in eye, picture taken from Opthobook.com

I have not taken things out of the eye before, but remember being taught how to back at medical school. The registrar on had also not done this procedure before and was caught up with a sick person which we couldn't get venous access on, and was trying to gain access with the ultrasound machine. I thought I would have a gentle try and if failed, would have to get the person to come back to see the specialist tomorrow. I bent the end of a needle and managed to use that to get the metal out of the eye. Very rewarding, but nerve-racking, poking the end of a long needle towards someone's eye and repeatedly telling them they have to hold very still!!

I also had a patient last night/this morning who had abdominal pain and a large mass at the lower part which felt like it could be the bladder. I have not had any ultrasound training but am always in awe of the more senior A&E doctors who can rock up with the ultrasound probe and diagnose heart failure, PE, pneumothorax and so on in seconds at the bedside. I thought I would have a go with the ultrasound (no radiation, nothing to loose) to see if I could see if this was the bladder.We normally have a special machine called the bladder scanner to measure for bladder volume but our department's one broke 6 weeks ago and is still apparently being repaired... Positioning the probe over the bottom of the abdomen I could see the large circular bladder, and using the measuring tools on the USS it was massive. We put in a catheter and 1 1/2 litres drained out. Although this is a very simple thing, it was very rewarding to be able to work out how to do something, make a diagnosis and be able to make a clinical difference to that patient.

I also managed to do a special nerve block to the femoral nerve for a lovely 90+ year old lady with a hip fracture last night/this morning as well! 

As you can see I have been doing loads with my shifts, and feel like I am learning lots of new useful skills. Sadly I have one of my professional exams coming up and having sunk over £300 into it I now need to spend much of my free time revising, as it is coming up next month! It seems there is no rest for the wicked.

Finally, I really hope that as junior doctors we do not need to strike, and the BMA and the government manage to re-enter negotiations, but given all of the poisonous rhetoric being put out but Jeremy Hunt, and the hatchet jobs appearing in news papers (most recently today in the Mail on Sunday) I think that it may well come to that. This is a huge shame, but a small price for us as a country and profession to pay for continuing the good work that the NHS can provide and preventing the destruction of the NHS and many doctor's lives.

Politics

Hi,

I haven't usually bought up politics on this blog, but that definitely doesn't mean I am not interested. The current government stance and rhetoric on the NHS and doctors contracts is very frustrating. I could go on about it for paragraphs as many (much more eloquent) people have done, but I will just recommend this blog by juniordoctorblog.wordpress.com which I feels summarises the governments response well, and critically analysis it (with referencing). I cannot thank the blog's creator enough for putting the time and effort into creating a much better thought out, and much more thoroughly researched piece than the current government.

God's balls

Hi,

Wow, it has been a long time since I last posted. This job is quite busy, but isn't busy enough to give me an excuse. I suppose I have just been distracted by other things going on in life.

I am on paediatric surgery at the moment, which is a big change to anything I have done before. I was pretty scared when I came into this rotation as I didn't have any paediatric experience previously, and it has taken me a little time to get my head around things. On surgery I am the only F2/SHO and there is usually a registrar and consultant on at the same time. As with most surgical specialities, they spend much of their time in theatre so I am left on the ward trying to work out what to do with my patients. Fortunately at the start of the rotation the general paeds team, who share the paediatric hospital with us, were very helpful. Sadly in the last month or so, due to politics which is well above my paygrade, they have been distancing themselves from my team so I have had to make do much of the time, but fortunately are still around in case one of my patients is genuinely ill. I am getting to spend some time in theatre as well, though, which is quite interesting, but I don't think surgery is the profession for me. The initial cutting is exciting but then all the searching around and stitching up layers is not!

The reason for coming to post today was an absurd situation I found myself in, and I felt I should share it. A 9 year old patient had come in yesterday with an acutely painful testicle. We were worried that this was testicular torsion - a surgical emergency which results from, surprisingly, your testicles getting in a twist. His mother was not keen on him having the surgery and it took about an hour and a half to persuade her that this was necessary. The surgery was performed overnight and found a torted hydatid - a little extra bit on the testicle which is the remains of the female reproductive organs (from when the boy was a foetus). This has no known function and is not important, and doesn't need surgery if it is diagnosed before the operation. The problem is, having a twisted testicle is an emergency and you don't want to faff about trying to work out which one it is with ultrasounds and the like if you are unsure - leaving the testicle twisted for too long will result in it dying permanently. In fact there is a surgical 'saying' - ""Testicular pain - don't engage brain"

The next day, the child was well and happy to go home, but the mum was not happy. I had been left to review this child, as the consultant and registrar had gone to theatre for a different case. The mum was upset that we had operated on the child and found nothing wrong, and upset that we had removed the dead hydatid of Morgagni which had been causing the pain. The reasons for this were that she knew that there was no problem with her child's testicle (hence why she was initially refusing the operation) because she was very religious, and she knew that God wouldn't want to harm her baby; she was upset that we had carried out the operation as she felt that God had been testing her faith and she had failed, showing she didn't trust in him to provide for her; and she was upset that we had removed the dead twisted tissue (why did God put it there if it has no use).

A picture found from the internet of an ultrasound of someone's testicle with the face of the Egyptian god of male virility in it

First, I was glad that the consultant was not around, as I would probably not hear the last of  him being compared to God in 'providing' for this woman. I wasn't too sure how to address her concerns though. I tried to explain that bad things did happen to kids (a point helped by being in the middle of a ward full of sick and disabled children); I tried to point out that perhaps the presence of the hospital was a way for God to provide for this woman in her time of need; and tried to convince her that we had no known function for this tissue, and its removal shouldn't affect her son in any way. She was not amused by my attempts at explaining things and kept trying to drag me into a theological argument. All of this was watched by the husband who was clearly on 'my' or the medical establishments side with regards to the need for the operation, but not keen on speaking up. I feel a lot of the passionate arguments the mum was giving were more for his benefit than mine. I am not a religious person by any means and was trying to keep things civil, but it took me an hour and a half to escape.

An hour and a half!

I was called back twice for questions about wound management by the nurses, which just turned out to be more theological arguments over why God wouldn't want to hurt this boy, and how he must have a special plan for the hydatid of Morgagni, if only we would wait and see. I felt that these recalls were likely due to the husband arguing things with the wife, so she would bring me back and argue them with me. Not ideal given we have about 20 other patients in the hospital at the moment to look after. The third time the nurses called me telling me she just had a couple more questions before she left, I asked them to tell her that I would happily come down if she promised not to talk about God anymore, and if she had any more questions of this nature then perhaps she should take them up with the hospital chaplaincy service. Unsurprisingly, she changed her mind and decided that she didn't need to speak to me any more. I will have to go back tomorrow and ask the nurse if they had to call the chaplain as an emergency to explain the reasoning behind an omnipresent, omnipotent, omniscient, benevolent God.