The good, the bad and the ugly

Hi,

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  

Good 

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."

Bad
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.

Ugly
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!

Miraculous
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! 

All the small things

Hi,

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

Deaths, difficult families and the worst day yet

Hi,

The last week was a terrible week. Very busy and a lot of difficult conversations with families when I didn't feel I had the time to give them the attention they wanted. My new rotation is gastrointestinal medicine, and it is very busy. The last week seemed to have someone dying every day. Many of these people were people with end stage cancer or other serious conditions, but this didn't make it any easier for me at all. The last 8 months or so I have been very fortunate and only had a couple of patients die - now it is terrible.

My week started off on call, where among others I clerked in a lovely gent who was in his 60s and had the same birthday as me. He had a pneumonia (I am still pleased with myself when I get a diagnosis, even one as barn door as this - makes me feel like a 'proper' doctor rather than a glorified PA) and his oxygen saturations (the measure of the amount of oxygen your blood is holding) were about 80% instead of the normal 95-100%. Other than this, he seemed pretty well. With pneumonia it is common to use something called the CURB-65 score to estimate how severe it is, and plan your treatment. This man scored 0, but I started him on the treatment plan for 'high risk' pneumonia (normally a score of 3 or more) because of his poor oxygen levels (not included in the CURB-65 score). A CURB-65 score of 0 suggests that this patient should have a 0.6% chance of dying from the pneumonia, but sadly 2 days later he had passed away. After having a good time joking with him about sharing a birthday, I was quite upset by this - especially as it had been so unexpected. I am pleased I had started treating him with intravenous antibiotics (as high risk) rather than oral antibiotics (as you normally would for a CURB 0 patient) as otherwise I would have felt as though I hadn't treated him properly, but I still felt upset over this. 0.6% still gives you that slim chance that someone may die...

Sadly the week got worse from there, cumulating in Friday which was the worst day I have had since I started work last August. It started off like a normal busy day, our ward works with 2 consultants who take it in turns to accept all new patients, and Friday is our day, so there was quite a lot to do. Part way through the ward round (up on the 2nd from top floor of the hospital) we get a bleep from the surgical ward (ground floor) saying one of our medical outliers has some chest pain. This happens a lot (invariably nothing) so I ask for an ECG and break off from the ward round to go down and check it out, expecting to be able to go back and join in a few minutes. I arrived on the ward, to be shown an ECG with good going ST elevation. 

ST elevation in an ECG from wikipedia 

I was panicked - what to do? ABC! MONA?! or should I be preparing him for PCI? I started treatment and then bleeped the cardiology registrar. No answer - I bleeped the other 3. No answers, so I dragged my registrar down away from the ward round to come and help me out. Fortunately it all went well, we continued ACS treatment (so many TLAs!) and the ECG changes went away, the patient didn't need PCI today (and he is still doing well)

Sadly, because my registrar and I were pulled away from the ward round (which the consultant completed on his own, as he needed to run a clinic in the afternoon) we were not too sure about the jobs that needed to be done. The SHO is in nights, and the registrar had to go to the consultants clinic in the afternoon, leaving me to work out what needed doing.

This is when the real trouble started. One of the patient's on the wards bloods came back with a high potassium, which means that they need certain intravenous medications (like insulin). I prescribed these medications while talking on the phone to one of the F1s from the acute medical unit. They wanted to transfer a sick patient to the ward from there, but needed a medical handover to do this. He explained that this patient was for palliative treatment due to her breast cancer which had spread extensively throughout her body, and she was too sick to be transferred to a hospice. He said she was already on a syringe driver with medications such as morphine to take away any pain or suffering, and just needed some TLC on the ward. I accepted all this and said I was happy for the transfer to happen. 

As I come off of the phone and hand the prescription chart to the nurse in charge of the ward, one of the other patient's relatives want to speak to me. He has end stage liver disease and is too old for a transplant, he currently has a bacterial infection in his abdomen which we are trying to treat with antibiotics, but not very successfully. It turns out that on the ward round in the morning, the consultant had been exploring the idea of going down a more palliative route with this man and his family. The thought being that the infection was only getting worse, and we couldn't give him a new liver to replace the old one that the alcohol had destroyed. It seemed that the way he had done this was leaving the family and patient (who was not well enough to process information) to think about what route they think would be best, as continuing active medical treatment would involve a central line, a nasogastric tube and more invasive treatment. Having thought about this from the morning, the family felt quite put out by this and felt that they were being asked to make a decision about whether the patient should 'live or die'. We were always taught at medical school that these sort of decisions should be made clinically, then the decision communicated to the family with their agreement - it isn't fair to leave this decision to the family, so I agreed with why they were so upset. I felt this was a decision a little too advanced for me to have to deal with, and went to pull my consultant out of his clinic to talk to the family, which he wasn't too happy with. It is decided that this patient is for full active treatment, and I need to find the 'IV team' who are the team who can insert central lines and suchlike. As it is a Friday, if I do not get these in today then we will have to wait for Monday, which means no antibiotics or fluid over the weekend, as we cannot get any venous access on this patient, which would not be good.

On getting back to the ward, a nurse told me that no-one had been able to give the treatment to the man with a high potassium, as the man had no cannula in to give intravenous drugs. It is about 5PM now and my official time to end the shift. I went to start setting up the equipment to insert a cannula and my bleep went off. I decide to answer it before putting in the cannula, as leaving it would mean they would keep bleeping me while I was inserting this cannula. It is the radiologist calling through an urgent report on one of my patient's scans. This lady has suspected bowel cancer (but not proven), and had been feeling a bit dizzy and faint so we had done a CT scan of the head. This CT scan had shown a very large mass in her brain which was squashing the brain up and starting to lead to coning within the brain (where the swelling squashes the important parts of the brain that control breathing and can lead to death). This needed urgent neurosurgical input, so I prescribed intravenous dexamethasone (a steroid to reduce the inflammation) and called the neurosurgeons to talk through what they wanted me to do. While on the phone to them, the nurse comes to tell me that they still cannot give my treatment for high potassium or the dexamethasone as no-one is trained in cannulation on the ward. I ask if they could call one of the other nurses from another ward to help out (though the neurosurgeon is not happy to be interrupted)! The neurosurgeons want an urgent MRI scan before deciding what to do.

I go to get the equipment to insert these cannulas when a very angry man storms into the nurses station and starts shouting that he needs to speak to the doctor in charge. I am the only doctor on the ward, so am asked to speak with him. He is visibly distressed and shouting about his mum; the lady with breast cancer who had been transferred to the ward a few hours ago. He is shouting things like  'why are you killing her' and 'What is this sh*thole anyway', and physically threatening staff members. I tell him I will happily talk to him at his mum's bedside, and go to look at the patient's notes to prepare myself for this conversation. By now it is about 7PM and I am left in the ward on my own. It seems that this lady with metastatic breast cancer has been known to the palliative care team for some time, and has accepted her diagnosis and the fact that she is dying. With this knowledge I go to speak to the son, at the patient's bedside. Her husband is also there. Her son is very angry, and stands with his face about an inch away from mine and shouts at me. I think about asking the nurses to get security, but decide that it might escalate the situation. It is understandable that he would be upset given the problem with his mum, and I don't want to make things worse. It seems that before the patient left the acute medical unit it was not explained to her son (who was not there) that she was dying and the decision had been made to make her comfortable, as there was nothing more we could do. In addition to this, she seemed very distressed when I was at the end of the bed - the medications she had been put on before transfer were at too low doses to alleviate all of her symptoms. I am stuck behind the curtains with this man accusing me of killing his mother, the poor lady who is visibly distressed and her husband who is just crying. The nurse pops her head around and reminds me that the two other patients are still awaiting cannulas, and they cannot give the steroid to the lady with the swollen brain, or the man with the high potassium (which gives him a risk of arrhythmias and death). I feel so out of my depth, but there is nothing I can do.

I ask the nurse who has popped in if she can give some more midazolam and morphine to this distressed lady, and continue trying to explain things to the son. He isn't having any of it, though, and has decided that I am too young to work there and he wants to speak to someone 'proper'. He wants to know which consultant made the decision for palliative care, so I tell him the name of the consultant who saw her in the acute medical unit. He storms off to talk to the consultant, and I try and explain things to her husband, but he is too busy crying. 

I put in the two urgent cannulas, and call up radiology who are not interested in performing an urgent MRI as it is now far too late. I have to explain to the lady with the mass in her brain that she probably has metastatic cancer which has spread to her brain, as she keeps asking the nurses why she has been started on dexamethasone - trying my best to not rush but to take my time and explain things gently. The acute medical consultant calls me up, not happy that I sent an irate patient down to bother him when he is busy. I am too tired to protest, or care.

It is now about 9PM, 4 hours after I was meant to leave. I still have most of my jobs from the day to do. The day on call has now changed to the night on call. I call up to let them know about the sick patients on my ward, and then get on with finishing off my day jobs. It would take longer to hand them over and explain the situations behind each patient than just doing them myself.

Before I leave, I check on the patient with metastatic breast cancer to make sure she is more comfortable. She is sleeping soundly. The son had gone home hours ago. The husband is still there, and he gets up, shakes my hand and just says "Thank you so much. For everything." The look in his eyes is all apology, he is so guilty for what his son was doing and saying.

I leave for home, physically and emotionally drained, but that handshake at the end made the world of difference to my week.

Confidentiality

Hi,


Firstly I would like to apologise for taking so long to update my blog, and explain why this has been. One of my colleagues at work approached me a little after the last post and asked if I had a blog online. I asked her why she thought this (obviously not wanting to admit this as its confidential etc etc) and she mentioned finding the blog online while searching for F2 application information, finding it interesting reading a few posts and from them feeling that 'it sounded a bit like you'. On reading further she found more information about what I had been up to in my F1 life (such as laser tag) and linked it to me, she didn't recognise any patients, though, despite being on surgery with me. This worried me, as while I anonymise all patients I mention in the blog, changing and mixing facts about them, I don't really want this blog to be linked to me personally. This isn't because I say anything in it that I feel is inappropriate in the blog, but I feel that being able to link it to me makes it more likely I will censor the emotions and opinions I want to write about. A recent news article over a hospital worker who was disciplined over making inappropriate comments on twitter (anonymously) also scares me. This operating department practitioner said some pretty silly things (such as planning on using a patient's body hair to make him sideburns like Bradley Wiggins) and rude things about the executive board. I don't think I have said anything this serious, but this man was trawled through the media, and investigated by a professional body and cautioned. I don't want this to happen to me.

I have had a good think, and a chat to a some friends/family about what they think I should do. I think I will carry on posting but I will try and say a lot less, just little bits about what I have been up to and some funny stores. Hopefully by keeping things brief (and professional) I remove even more patient identifiable data, and minimise the information that people could use to identify me.

Over the last months so much has happened. Most importantly (to me) my favourite patient sadly died. This was someone who had been in the hospital for well over 100 days from when I was doing surgery. I have talked about them previously in the blog, and while on nights last week I was called to an arrest in the surgical ward. On arrival it was this patient who had arrested (completely unexpectedly) and we did all we could but couldn't restart the heart. I was really affected by this happening at 4AM, while I was trying to look after another patient on a different ward who was getting sicker and sicker (and subsequently died), and I had to go and sit down, have a little cry, and wonder if this was really the right job for me. Having had some time to reflect, this is the right job for me, but I am going have to get better at coping with things like this happening. I have been very lucky so far that not many of my patients have died, but things can only get worse...

And for some quick bullet points to get across some of the more eye-catching things that have happened since I last posted

- Homeless heroin user on the ward, complaining about the service that we could offer them. They are telling us on the ward round that 'they pay taxes too, and should get more methadone'. My consultant replies curtly 'there is no VAT on Smack' and walks off. Ballsy and it took some time trying to persuade the patient to stay in hospital afterwards, but very brave!

- On call repeated bleeps from 'outside lines' (often the consultant calling from home to make sure you are doing OK) actually turning out to be recruitment agencies trying to get me to join up. Lying through switchboard to get to medical people working then trying to sell. Not the best time guys!

- 30 year old obese man came to hospital with breathing problems, got stuck in his car in the car park and had a cardiac arrest: the paramedics had to dismantle the car to get him into the hospital. Fortunately he survived. It was thought he arrested because the getting trapped inhibited his already problematic breathing by putting pressure on his chest, leading to a respiratory arrest.

- A man I was clerking telling me he had a 'cauliflower heart'. Very confusing until I realised he meant he had had a Coronary Artery Bypass Graft (CABG or cabbage in medical slang)

- Behind curtains seeing one patient while another talks on their phone, unaware we are next door "get some of those chocolates for the doctors when you come in, they have been lovely.... No not those ones, they are too dear, get the 2 for £5 ones, then we can keep one" Then looking sheepish as we come to see them next on the ward round

- A patient telling me 'that was a really good session' after I performed a digital rectal examination on him. Needless to say I didn't go back and see him again, and left it to my colleagues instead!

My posts may take more of a vibe like the above in future (though more frequent, and less long). let me know what you think (if anyone is actually left reading this after this hiatus!

The one sandwich to rule them all

Hi,

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!

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.

Luck of the Irish

Hi,

So much time between posts - time is flying at the moment! So much for my decision to do little and often, I will just have to work with what I can do I guess!

The last few weeks have been pretty hectic, some F1s were off on holiday/sick and I had to cover for them. Really not an ideal system as I already spend the day working, so I am not sure how I am meant to do two jobs at once! Fortunately I just about survived that staying a bit late and getting others to help out. As I said before, having helpful colleges makes so much difference! This week just gone I have been on call, and it is absurdly busy. The on call team consists of - F1 (me), SHO (few years more experience) Registrar (surgeon) and consultant (on for whole week, 24/7, but somehow at home all week at the same time). These 4 people (realistically two, as the consultant is at home waiting for some kind of emergency he will need to do, and the registrar in theatre doing the operations) have to see all new people who come in under surgery for that week. The start of the week was really good, as we started with no patients, as the team on call last week had taken those who had come in under their care for their normal day-to-day work. I got to spend the the first few days clerking in new patients, working out management plans and diagnoses- all very interesting and the side of medicine that I think I enjoy the most. As the week progressed, however, we ended up with dozens of patients under our care; the SHO was having to clerk in all the new patients on her own. This is any patient referred to the surgical team at all, from patients coming in through A&E with appendicitis, to patients who GPs send in due to problems they have presented with, and referrals from district nurses. Could be 10-20 people a day. I couldn't help her with this, as I was trying to sort out all of the patients who we had admitted on the ward, with all of their various problems. Very hectic, and I am glad it is over and I can go back to my day job next week.

The highlight of the last week was the mess social. The mess presidents organised for us to go to laserquest, which I won convincingly. Success! There were also a number of other bonuses over the last few weeks, including the hand over I got from the night team when I was on call which stated, in all serious "The patient was Irish, but denied any excessive alcohol intake". Sadly for the stereotype police, he had alcohol induced acute pancreatitis... 

The people you work with...

Hi,

I have been thinking a lot about how the people you work with influence how much you enjoy your job. I work with some real characters, for better and worse, and I think that the people who you work with are the main factor which affects whether you enjoy going into work in the morning.

For example, there is the nurse in the pre-op assessment unit who calls me 'Mr Vascularity". I am pretty sure that this isn't something to be proud of, but it always makes me feel noticed (and certainly puts a smile on my patient's faces). It is nice to feel as though you are not just another person wandering around the hospital, but people notice and remember you, and enjoy chatting with you. Especially friendly motherly nurses who help look out for me!

My consultant is pretty much the opposite. He is the 'typical' surgical consultant, very blunt and brief with patients, and difficult to approach. My favourite quote from him this week (and keep in mind I only see him once a week, for his weekly ward round, the rest of the time he spends in theatre, clinic or in other hospitals) was while he was on the phone to a member of office staff. I think someone had had to move his list around to a different theatre which he was less happy with, and this poor office worker had to tell him. I caught the consultant telling the person that.

"I am going to show you what happens when a consultant throws his considerable weight around"

Needless to say, I don't get on very well with my consultant, but fortunately rarely see him. As long as I have my pockets full of gloves and pairs of scissors for him to look at the post-surgical wounds of the patients on the ward, he seems to tolerate me...

So moving onto the other most important group of people I work with. Seniors are obviously important, as are nurses and other clinical staff. The third group is my peers; other junior doctors. On the whole, the juniors at this hospital have all been so supportive of one another. It quickly became apparent who was quite highly strung and got stressed about most things, and who was lazy and would try and avoid as much work as possible, but on the whole I have been very lucky with this bunch of people. The surgical jobs come in waves, with certain firms being much  busier than other firms at any one point. People from the less busy firms seem very happy to come and help those who are much busier. I have been helping others for a few weeks but have been very busy recently, and very glad of the help coming my way when it seems like I will have to stay past 8PM to get things done. One of the other F1s even bought me a pack of Maltesers as I looked tired out from all the running around hospital. How lovely; it is those little things that make the day easier! 

Corridor collapse

Hi,

Again, I start with an apology for the time since the last post - I will try and remedy this by posting little and often in future. The past few weeks have been very busy - the senior house officer (an F2) in my vascular surgery rotation was off, leaving me to deal with basically everything, and then the breast surgery F1 was off, meaning we had to cross cover breast surgery as there are no other juniors on that rotation, leading to another week of heavy work. All in all, I think that next week, now that everyone is back, things will be a lot easier!

Things have been getting easier as the weeks go by and I get used to things a bit more. I have been working as an F1 for about a month now, and I am getting much more used to not only how the job works but (supposedly more importantly) how my consultants like things done. I can have lists prepared at the correct moment, make sure that surgical lists are in the order that each consultant prefers and try not to get in anyone's way so they trip over me...

A couple of exciting/stressful (they often seem to be both...) things happened to me this week. One of my patients became very sick whilst I was trying to run my pre-op assessment clinic. I was meant to be spending all afternoon assessing a stream of patients to try and tell if they were well enough for surgery or not, but had the surgical 'advanced care' unit calling me telling me one of my patients had a heard rate of 30 beats per minute (very low) and a very low blood pressure. My registrar had gone home for a half day off, and my vascular SHO (year on from me) was stuck looking after a breast based MDT which is a big meeting, so I couldn't contact him. The decision to go to the patient and see what I could do was clearly more sensible than staying in clinic, but once I went to the sick patient, people started queueing up in clinic waiting to see me. I ended up being with the sick patient for about 1 1/2 hours so built up a number of patients waiting for me (who were very understanding, the worst being someone grumbling about the car parking fee after waiting so long). The patient had fluid in his lungs (pulmonary oedema) which meant that giving lots of fluids to try and bring up the blood pressure wasn't such an easy choice to make. In the end I gave him 250ml of fluid over 30 minutes to see the effect on his blood pressure/heart rate/urine output (urine output was basically 0 for the last 6 hours), asked for a bladder scan in case his catheter had become obstructed leading to the poor output, and called the critical care outreach team to help me. Sadly, they took some time arriving (hence why I had to stay there for so long) and my interventions didn't do very much. In the end, when they did arrive, the ended up giving atropine and glycopyrrolate (drugs I wouldn't have dared to give on my own). He ended up going to HDU (a ward which is one step down from ITU) but from there improved and seems well now.

The cause of this profound bradycardia (slow heart rate) isn't really known. At first, the critical care team though that, as this sick patient had been on digoxin then received a spinal anaesthetic, it could be these two interacting to block the sympathetic nervous system and slow the heart. I thought it could be digoxin toxicity. We took the blood to test for dogoxin levels, but the lab only does these once a week (strange and unhelpful).

Later on this week, a person collapsed in front of me while I was hurrying through one of the corridors to request an MRA scan for one of our in patients. I was in a real rush as it was almost 5, and I needed to catch the radiologist before he left the hospital (and my consultant had specifically said it needed to be requested today, so it could be done early tomorrow so she could then leave for dialysis). Obviously, I had to stop and try and help out. This lady was in her 80s, and wasn't a patient at the hospital, but was just visiting a friend. She had started walking down the corridor but had found herself very short of breath. I asked a few library staff who were walking down the corridor to get me a wheelchair, and call the medical emergency team while I took her pulse and tried to talk to her. Being in a corridor was very awkward as people were all walking by next to us and staring. Taking the pulse was much less invasive than trying to listen to her heart in this situation, so that was all I could do, and she was very tachycardic (fast heart rate) with a heart rate near 150. She was also very breathless and seemed hot and sweaty. Added onto the fact that she had had a lot of heart problems in the past, I was very worried! By the time the medical emergency team arrived, she seemed a lot better, her heart rate was more normal, and she wasn't breathless or sweaty anymore. They seemed a bit confused as to why I had got them to run all the way out here to this corridor! In the end, they said that she should probably go to A&E to get checked out, so I wheeled her there in the wheelchair. I wish I knew what had happened after that, but sadly I had lots more to do that day and ended up staying quite late in the hospital, so I didn't get to follow up what had happened. I did feel a bit of a wally after calling the medical emergency team, but I know that it was the right thing to do after she had presented in such an alarming way...

Long weeks

Hi,

So I have been working as a 'Junior Doctor' for about 2 1/2 weeks now, and it has been really busy. For the last 2 weeks I have been in the hospital every day, as I was on call over the weekend. All of these long days, added to the fact that I have only just got internet in my new house have lead to this relative silence on the blogging front, but hopefully this won't be too common (though I have no idea how things will go for the rest of the year busy-ness-wise!)

I am on a vascular surgery rotation for the next four months, and on normal week days my job isn't too hard. I have to stay relatively late sometimes (I am meant to work 7.30/8 til 5, but sometimes need to stay til 8 or 9) but during the day the things that need to be done are not too challenging. Most of the other surgical teams at the hospital consist of an F1 doctor (or several if busy teams), an SHO or two (a doctor who has a year or a few worth of experience), a registrar or two (a relatively experienced surgeon) and a number of consultants (who are the most experienced surgeons and run the theatres and patients in the hospital). Sadly, my team is much smaller, as I am currently at a smaller district general hospital, and most of the vascular surgery is done at the nearby(ish) large teaching hospital. There is myself and an SHO who is a year ahead of me in terms of exprerience (he has done an F1 job already), but other than that we have very little. There is no assigned registrar for vascular surgery (we have to steal another
teams one if we have problems) and the vascular surgery consultants work most of the time at the large teaching hospital, meaning we see one of them once a week for a ward round. All of last week my SHO was on nights, meaning I was left alone to try and organise the ward patients.

While this is a little scary, it isn't as bad as it sounds. Most of my patients are relatively well, and are in the hospital for rehabilitation. This is because most of the seriously ill patients are sent to the teaching hospital for their surgeries (cases like major amputations and ruptured AAA), while my hospital does small, more simple procedures like removing varicose veins, and accepts patients once they are medically well from the large teaching hospital for rehabilitation. This means that I don't usually need to worry about really sick people, and instead need to fuss over blood sugar control in diabetics, and warfarin doses controlling INR. Good practice to start off my F1 job, as it lets me get used to how all these things work, but not too exciting as what I really enjoy is the challenge of diagnosing and treating sick patients. When something does go wrong, though, I am left floundering a little - as there is no-one around to help (for example when I was asked to come and remove a stuck PICC line as an 'expert' [turned out it just fell out])

Despite this, my patients (and I do love saying 'my patients' now, still feels unreal) do tend to stay in the hospital for some time while we treat infections or help them get used to walking again, so I have plenty of time to build up relationships with them. This is something that I have been doing well at, and have had lots of lovely things said to me about my bedside manner by patients and nurses. Always nice to have compliments when you are having to stay 3 or 4 hours past your normal home time to clerk in a patient who was meant to arrive in the morning, but came into the hospital in the evening and needs to be seen.

My on call weekend was very different to my normal day job. Here, there are two F1 doctors (myself and another), who work under an SHO and a registrar to try and run the hospital over the weekend. This is crazy busy, as people get sick at the sme rate, but instead of the normal teams which is probably about 30-40 surgical doctors during the week, there are about 4 of you. The registrar has to spend most of their time in the operating theatre doing procedures, and the jobs come thick and fast. Prioritising is very important, but some wards seem to want to badger you for relatively unimportant jobs while you have more going on. Through a large chunk of Sunday I had to go to theatre to assist the surgeon by providing another pair of hands to hold some of the instruments, meaning the ward jobs built up even further. All you could do was try your best to do the most important jobs, it seems like a very silly system.

After on call and this double week I was feeling very tyre'd...

All in all, I have been happy this week go go back to a more normal job with patients I know, but I am really looking forward to the coming weekend and having some time off! Very thankful that I am not in for the bank holiday Monday though - that is going to be hectic!

Trepidation

Hi,

Here I am, sitting at home, getting ready for an early nights sleep, but anxious about tomorrow. I have completed a few shadowing days working with the F1 who currently does the job that I will be doing from tomorrow onwards as Dr Internal Optimist.

The shadowing days have been a mixed bag. There were a few boring days of lectures, then a big night out with the other incoming F1s on Friday to 'get to know' each other. A good start! This week we have had a couple of days on the ward, following the current doctor doing our jobs - mine was very good - very well organised and had loads of time for the patients. I have to remind myself that he has a years worth of experience on me, and is effectively now an 'SHO'. I hope that I am not expected to be quite as efficient when I start, but I will definitely try!

In the past few days, I have been quite effective, spending a lot of time trying to get patients with problems home from hospital, the most difficult one being someone who is a drug user, has no home, no GP, but we need to discharge while keeping his medications going (so he doesn't turn back to heroin again) and keep his wound dressed. Trying to get a hostel or home to take him was difficult, but he couldn't live in hospital for the rest of his life. He is meant to be going home tonight, hopefully when I go in tomorrow for 'Black Wednesday' he will not be there.

I think it is the things like that where you can make a huge difference by pushing a bit and making an effort, rather than just leaving things to sort themselves out over weeks. I hope I can keep up the good work over the next few months.

Wish me luck, I will keep you updated!