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.