Mangling Medical Careers

When I started this blog, I deliberately tried to avoid writing about Modernising Medical Careers (MMC) because the whole debacle pissed me off so much and I’d just get really angry whenever I thought about it.

It’s now two years since specialty training and recruitment came under the MMC umbrella, so I thought I’d revisit the subject to see if the powers that be have managed to iron out the problems the new system had at its inception.

One of the key concepts of MMC, the new post-graduate training system for doctors, was to end the “lost generation” of Senior House Officer (SHO) junior doctors who spend far too long in SHO posts and face far too may barriers to career progression.

A quick look at the MMC website shows how beneficial the changes have been to junior doctors. They’ve got rid of the name “SHO” and given us names like CT1, ST2, FTSTA2, ACCS1 etc… etc… but the jobs that we are doing are essentially the same, so I’ll refer to all these posts as “SHO” in this post to try and avoid confusion. All SHOs would like to progress to being a Specialist Registrar (SpR) with the long term aim to complete our training and become a consultant.

MMC has renamed the SpR posts as “ST3”

Now, lets say that you’re a junior doctor and are coming to the end of your two or three years as an SHO and want to move on to an ST3 (SpR) job next year to progress your training. Oh, and lets say that you want to stay roughly where you live at the moment because that’s where your friends and family are.
For the specialty of anaesthetics, let’s see exactly how many jobs there are to apply for in England & Wales in 2009.

East Anglia and the East of England – 1
East Midlands – 2
Kent, Surrey & Sussex – ZERO
Manchester, Lancashire and the North West – ZERO
Newcastle & the north – ZERO
Oxfordshire – ZERO
Cornwall, Devon & Dorset – ZERO
Bristol and the Severn area - 1
Wessex – 1
West Midlands – ZERO
Yorkshire – ZERO

All of Wales - ZERO

In fact, the only places where are any vaguely sensible numbers of jobs are Liverpool and London. If you happen to live anywhere else, you’re going to have to move. In the whole of the country, there is a sum total of 55 jobs available in 2009. My back-of-an-envelope calculations tell me that there’ll be in the region of 350-450 doctors wanting one of these 55 jobs. What happens to the people who don’t get one of these jobs? Nobody knows, and the impression that I get is that nobody really cares. The situation is even worse for doctors who want to be surgeons, paediatricians or physicians.

Remember that the stated aim was to PREVENT barriers to career progression. How can a system that’s been six years in the making fuck things up so badly?

Happy Christmas

I wish you all a very Happy Christmas indeed.

Pink or Blue?

It was a few months after I’d started my anaesthetic training and I was slowly becoming more confident (and competent) about giving general anaesthetics safely. I was going a general surgical list and Dr James was the consultant anaesthetist in charge. Dr James said that she was going to “loosen the reins a little” and told me that I was going to look after this list by myself and that her role that morning was to “drink coffee and administer the occasional bollocking.”

So I got cracking and things were going well. True to her word, Dr James made various cameo appearances throughout the morning and “questioned” my choice of drugs and anaesthetic technique. The last man on the list was a 77yr-old with a few medical problems. Of all the people I had to put under that morning, he was the one I was most concerned about.

Anyway, I get him in the anaesthetic room, do all the per-op checks with the ODP (anaesthetic assistant) and get the monitors on. I put in a drip and set about getting him anaesthetised. I figured that he wouldn’t need much of my induction drug, so I slowly trickled in the propofol.
Despite my caution, things started to go wrong. After he became unconscious, I was able to bag-mask ventilate him OK and I after I put in the LMA, his chest was rising and falling, a sign that I was getting oxygen into his lungs. Despite this, the monitor was showing

O2 sats: 77%

And this is bad.

The ODP was a man called Edward, who was very experienced – in fact I believe he was set to retire in a couple of years’ time. Edward looks at me and says “Sats are low”

“I know,” I reply as I turn to oxygen up to 100%
“Is the LMA in properly?” he asks.
“I reckon so”
“Are you sure, I mean sats are only 75%! Do you want to take it out?”

I really didn’t think that this was an airway/ventilation problem and the fact that the blood pressure cuff was taking an awful long time to give me a reading made me think that the problem was that the patient didn’t have a blood pressure.

“No, leave it in,” I say.
Edward looks at me incredulously. “Well, what do you want to do?” he asks. “Shall I call for Dr James?”
“Yes, please do.”
Edwards kicks open the door to the operating theatre and yells at the theatre nurse to go and get Dr James NOW.

I look at the monitor again, it still says that the sats are 75% and, rather ominously, this mans heart rate had dropped from 70bpm to 45bpm.
“Edward. Squeeze this bag for me” I say and I open the cupboard to get out some emergency drugs. I pause for a second to consider which inotrope to use and at that moment, Dr James bursts into the anaesthetic room.

She looks at the patient then looks at me, then looks at the patient again then looks at me. “What’s going on?!” she exclaims.

“Hypotension… and bradycardia.” I mumble
She bags the patient and asks, “what have you got in your hand?”
“Atropine.”
“Ok, give 300mics”
I do so, and seconds later, the patient is better. Sats read 95% and the blood pressure is back to 133/58.
“How much propofol did you give?” Dr James asks me
I look at the syringe that is sitting on the anaesthetic machine. “105mg altogether”
“That’s not a great amount is it?”
“No, not really. I was actually really surprised that such a small dose had such a massive effect on this man”
Dr James shrugs and says “sometimes it happens like that.”

We get the patient through into the operating theatre and onto the theatre table. Dr James laments, “whenever I get called into the anaesthetic room, my first question is: ‘Pink or blue?’”

“Pink or blue? I’m confused”
“As in; ‘Is the patient pink or blue?’ This man…” she gesticulates at the patient on the operating table “was pink. So I knew things weren’t too bad.”

I mentally raise an eyebrow at this. I’m not sure how bad things have to be before Dr James gets worried.

“You did a good job,” she says and literally pats me on the back. “Carry on…” and with that she saunters back out of the operating room, presumably back to her coffee.

Edward and I look at each other and shrug as the surgeon starts the operation.

Christmas Bonus

My girlfriend got her Christmas Bonus the other week. Because of her hard work and dedication though these difficult economic times, her company has given her £1000 to say thank-you for all that she’s done for them in 2008. What’s more she’s now out dancing the night away at her company’s Christmas party, with free drinks at a venue all paid for by her company as a thank-you to the staff.

I got my Christmas Bonus yesterday. As a reward for all my hard work and dedication over the last year, my company gave me a £1.50 discount voucher for the Christmas Dinner. It meant that only had to pay £3.00! I feel so happy that all the extra (unpaid) hours I put in have been recognised. That I get some recompense for all the occasions that I’ve done extra shifts to cover the gaps in the rota. That my hospital wishes to thank-you for all the unsupervised lists that I did – not because it helps my training, but to cover for absences and make sure that operations don’t get cancelled.

Such is life as a public sector worker.

It’s not all bad though. After I paid my £3.00 for the Christmas Lunch, I got a “free” Christmas cracker – so I can’t complain too much, can I?

Hi! My name is... My name is... My name is...

DrJDR posed me this question in a comment to a post that I made earlier in the week

I wonder what you think about the whole 'first names' question? That is, should
you (the doctor) introduce yourself by your first name - such as 'My name is
James, I'm a forensic psychiatrist'? I remember being told off in an exam for
doing this kind of thing, and since then I've always been very careful not to
use my first name and stick to surname - ie 'my name is Dr Blunt' (well it isn't
really, of course). I think that this does set the professional boundaries very
clearly which I think is important for patients. I used to constantly cringe
when hearing young nursing staff / assistants breezily addressing sick old men
and women on their first meeting by using their first names. I always thought
this inappropriate, and personally I would not like to be called by my first
name by someone I had never met. Professionalism in medicine as a whole is
something which has really suffered, and which I think we need to keep going.
Patients expect us to act in a professional manner, and when we do this gives
them confidence in us.

To be honest, I have no hard and fast rules about which title I use to introduce myself. I’ve used “Michael,” “Dr Anderson” and even “Dr Michael Anderson” depending on what seems most appropriate at the time. I have to say that my “default” when introducing myself to an adult or late adolescent is “Dr Anderson,” but I do vary it – yesterday's post for an example.

When addressing patients, I tend to use their full names to start with and then I’ll use their surnames for the rest of the conversation, unless they tell me otherwise. So, generally, it goes something this:

“Good afternoon, is it Amy King?”
“Yes, it is.”
“Pleased to meet you, my name is Dr Anderson, I’ll be the anaesthetic doctor for your operation later on today. Is it Miss or Mrs King?”
“Mrs, but please call me Amy”

Patients are frequently extremely anxious when I see them pre-operatively and you’re right, that professionalism and good communication are incredibly important.

With children, especially young children, I do tend to use first names more, but again, this is no hard and fast rule, and I'll often use surnames with children as well. It depends on the child.

At the end of the day, part of my aim is to try and make the person I'm talking to feel as comfortable as I can using whichever names I feel fits the situation best. It seems to work pretty well for me, but no doubt there's occasions where I've got it wrong and no doubt, I'll get it wrong in the future, after all, every person is different.

I do call patients “dear” or “my dear” occasionally, (yes, I know we’re not supposed to) but again, I’ll do this only when I feel it’s appropriate and certainly not until I’d built up a relationship with the person that I’m speaking to.

A Sliver of Hope

It's 9pm and I'm on nights once more. There are no emergency operations to do, so I'm in the intensive care unit, helping out as best I can. Bindhu is the registrar on call tonight and is my direct senior for the shift. We’re walking round the unit and she’s giving me a brief handover of all the patients as we do so.

We pause at the end of one of the beds and I recognise the lady in it. It’s Mrs Campbell. Last week, I’d pre-assessed her for her emergency operation and then handed over her care to the anaesthetist on call during the day time. I smile at her and receive a tight grin in return.

"You won't get much out of her," says Bindhu. I give her my best "quizzical" look, so she elaborates. "It's a bit strange. Every time I try to speak to her she won't answer me, or even acknowledge me, but when I watch her with the nurses, she seems to be completely different. Mind you, she's apparently been a bit better today. In the daytime, they made the surgeons come down and explain to her what went on - or should I say, what went wrong - with her operation and explain what they're planning to do about it. I mean, it's only fair isn't it? I don't see why we (anaesthetists) should have to take the flak, when really the cause of her problems is nothing to do with us."

"Indeed." I reply. "I'll bet you that I can make her smile though."

Bindhu throws her head back and gives one of her lilting little laughs. “Good luck with that,” she says and we move on to talk about the next patient.

It’s now 11pm and Bindhu and I have done all the pressing things for all our patients on the intensive care unit. The nurses have just turned down the main lights, so the room is illuminated by soft glows coming from the lamps at each patient's bedside.

I walk up to Mrs Campbell’s bedside.

“Hello. Mrs Campbell,” I say softly. Her eyelids flicker open and she fixes me with a cool stare. “Do you remember me?” I continue.

She rolls her eyes away from me. “No. I don’t remember you,” comes her flat reply. “I don’t remember… anything. For the last few days, I don’t remember anything.”

This doesn’t come as a surprise to me as she’s been in a coma on a ventilator until a couple of days ago, but I suppose I was hoping that she’d at least recognise me from before her operation. I was wrong.

“My name is Michael, I’m one of the anaesthetic doctors and I saw you before you had your third operation. I just wanted to see how you are feeling.”

“How I am feeling? How am I feeling?” she seems to ponder the question for a while, like she’s rolling the thought around her consciousness. “I feel lousy.”

And then there’s The Silence.

I like to think of myself as a pretty chatty, outgoing person who can talk to just about anyone, but every now and then, I find myself at a loss for anything to say at all.

Here I am, late at night standing next to a woman with several tubes coming out of various parts of her body. A woman who’s just come out of a coma and is too weak to even feed herself. I feel that there’s just no way that I can relate her and what she’s had to go through. There’s no way that I can understand how she must be feeling. There’s no way that I can put myself in her position or even begin to imagine what it must feel like. I fear that any words of comfort that I might attempt will sound trite in the face of this lady’s experiences, so I’m left with no words at all – just The Silence.

As The Silence stretches on, it begins to feel more and more uncomfortable. I’m just standing next to her bed saying nothing, feeling stupid, so I’m compelled to try and just say something, anything at all.

“Yeah, I understand that you must feel pretty lousy right now. Am I right in thinking that you’ve been able to have a chat with the surgeons about the operation?”

She sneers at me. “Oh, I know what they’re planning to do tomorrow. And I know what they’ve done.” She looks away from me again and stares in the direction of the far wall, which has silver tinsel draped along it. “They’ve given me a stoma.” She spits out the last word, like it’s a piece of rotten fruit she’d accidentally bitten into.

She looks back at me now and meets my gaze. I realise for the first time just how piercingly blue this lady’s eyes are. She sighs. “My sister had a stoma,” she says, her voice is a mere whisper.

“And you really didn’t want one…”

“I cared for her for years… For years. That’s her picture over there.” She gestures to the photo frame at the side of the observation chart. I go and pick it up and look at the picture.

“What happened to your sister?” I ask.

“She had MS. And cancer. I spent years looking after her, and looking after my mother. We were inseparable, you know? And do you know what’s funny? During all the time I was looking after her, I knew that there was something wrong with me. But I had to be strong, you know? For her. I’m a very determined woman. But I knew there was something wrong. But I never thought I’d end up just like her.”

“I know this is easy for me to say,” I respond, “but you must try and stay positive. You are getting better. I know you must feel awful now, and there’s a long, long way to go, but, hopefully each day you’ll feel stronger and, as you do so, you may be able to look forward to the future. You’ve just got to try and think…”

“That God knows what he’s doing?” she interjects.

“I guess so.”

“Last Christmas was hard…. very hard. My mother died. She kept saying ‘I want to be with my daughter. I want to be with my daughter’ She kept saying it again and again…” Her voice trails off and tears well in her eyes. “And now she is,” she whispers.

“I saw her last night, you know,” continues Mrs Campbell. “My sister. She was stood over there near the door…”

I wait for her to continue, but there are no words coming. Once more The Silence envelops the two of us.

“Yesterday, I didn’t want to live,” she says. “I’ve got nothing left to live for. Yesterday, I really didn’t want to go on. But today… Today I feel better. I’ve got a dog, you see. I have a little dog that loves me, and I love her. So I’ve got to get better haven’t I? For my dog.” She gives a little laugh. “That dog saved my life.”

“That’s something,” I say. “And as you get better, and are able to do more things, then I’m sure things will start to look brighter. I’ll leave you to get some rest now, Mrs Campbell. Sleep well.”

She closes her eyes and I walk away.

My name is...

One of the things that was drummed into me again and again at medical school was the importance of introducing myself to my patients. In every single undergraduate clinical exam and every single postgraduate exam I have every sat, there have been marks allocated for introducing myself to the patient at the start of the interaction.

Personally, I used to think that being told this again and again and again was really tedious. After all, it’s just good manners isn’t it? I always introduce myself when I meet a new person and patients are no exception.

“Mr Smith? Good morning, my name is Michael. I’m one of the anaesthetists, do you mind if I ask you a few questions?”

or

“Mr Smith? Good morning, my name is Dr Anderson. I’m one of the anaesthetists, do you mind if I ask you a few questions?”

When I first started my anaesthetic training just over a year ago, that was how I’d introduce myself to my patients.

When I first started my anaesthetic training just over a year ago, I’d frequently get blank, uncomprehending looks from the person that I was talking to. Sometimes, people would try to be polite, but it soon became obvious that they had no idea who I was or what I was planning to do to them. You see, it became very obvious, very quickly that, generally, people have very little idea what anaesthetists do, so introducing myself as an anaesthetist didn’t shed much light.

Since starting my anaesthetic training, I’ve had some cracking comments about my job – often from people who (I thought) really should know better.

“Oh, I didn’t know you had to be a doctor to be an anaesthetist!” – from one of FashionGirl’s friends

“If you’re an anaesthetist, all you do is give an injection – and that’s it. Well, that’s what happened when I had my operation. Why do you have to train for seven years to learn how to do that?” – from my own mother

“Once the patient is asleep, you guys don’t do anything do you?” – from a surgical FY1 doctor

“But what do you DO?! I don’t understand what you do. NOBODY understands what you do.” – from my former housemate who is a cardiology registrar (he was v drunk at the time).

“So, are you a doctor then?” – from a patient just after a ten-minute discussion about epidurals, invasive lines and HDU after care.

…and it goes on and on and on.

Over the year or so I’ve been doing the job, I’ve noticed that my simple introduction to the patient is starting to sound more like a job description. These days, I’ll say something like:

“Mr Smith? Good morning, my name is Dr Anderson. I’ll be the anaesthetic doctor for your operation later on today. It’s my job to give you your anaesthetic and to look after you while the surgeon is operating. Do you mind if I ask you a few questions?”

It’s a bit wordy, but it seems to set the tone a bit better and I seem to get a few fewer blank looks.

Apologies

Apologies for my lack of posts recently, I've actually been caught up with the "non-work-related work-related" stuff that can eat into significant chunks of my free time. I've been working on a teaching session, an audit and I've been trying to put together a case presentation as well. Once again, I feel I have my finger in too many pies at the same time - but to be honest with you, I actually prefer things this way.

My girlfriend told me that I always seem to have two or three projects on the go at the same time, and it's probably true. I guess I'm happier that way.

I'll be back posting again very soon.

Holby Shitty

Usually, I don’t watch hospital dramas on TV. Shows like Casualty and ER actually annoy me because of the ludicrous events and people they portray. It’s made even worse by the fact that these shows generally make doctors out to be almost universally arrogant, incompetent morons whereas nurses are level-headed, sorted people who always seem to know exactly what’s going on. The last time I actually watched one of these shows the whole way through, I was treated to the sight of a consultant cardio-thoracic surgeon clerking in a patient with vague chest pain in A&E! Apparently, the newer shows like House and Grey’s Anatomy are better, but to be honest, watching these things is a bit like a busman’s holiday for me and I’d much rather spend my precious free time doing just about anything else. The exception to this rule is Scrubs, which is consistently brilliant, but I’d hardly describe Scrubs as a “hospital drama.”

The reason hospital dramas have come to my attention again is the latest episode of Holby City which in which the plot has reached such a ridiculous low that people were actually talking about it in the theatre coffee room yesterday.

As far as I can make out the plot goes like this. The anaesthetist, who everyone hates, is acting like a total tosser in theatre. He then starts dicking around with the (charged) defibrillation pads for no reason whatsoever. This being TV, he manages to give himself an electric shock with them. Cut to scene where he’s now being given “life support” by one of the surgeons and an ODP. When I say “life support” I mean it in the vaguest possible way. He’s given random shocks and oxygen but there’s no cardiac arrest team, no CPR (as in - not one single chest compression!), no IV access, and no drugs given. Surgeon 1 turns to surgeon 2 (who I presume is the consultant), who is doing a great job of ignoring all this and is carrying on with the operation regardless, and says “it’s not working” (no shit, Sherlock!). Guess what the consultant’s response is? “Put out the cardiac arrest call?” “Get some more help?” “Do some basic life support?” Nope. He responds by declaring the anaesthetist dead! To top it all off, the monitor still shows ventricular fibrillation. Unbelievable.

The plot rumbles on. No one in theatres or on the ward mentions what’s just happened (like this is an every day event or a “risk of the job”) and we cut back to another scene featuring surgeon 1. Remember that one of this man’s colleagues has just died and surgeon 1 is partly responsible due to his overwhelming, unbelievable incompetence in an emergency situation. A St Johns Ambulance volunteer on their first day would be embarrassed by surgeon 1’s behaviour, never mind a supposed senior hospital doctor. Now a bereaved and grieving family will have to bury their son/dad/husband/brother. Is there any remorse shown by surgeon 1? Is there any guilt that his failure to act resulted in the death of a work colleague? Nope, of course not. He’s shown laughing about the whole thing in the bar with one of the nurses!

I thought that people were taking the piss when they described what happened on the show, but thanks to BBC iPlayer, I got to see the sorry saga for myself. If you want, you can catch it here, the episode is called “Cutting the Cord” and, if you understandably can’t bear to sit through the whole thing, the fun starts at about 41 to 42 minutes.

It begs the question, have the people who write the scripts for these shows even been to a real hospital or ever spoken to real NHS workers? Judging by what I’ve seen the answer is obviously not.

Advice given to me as a child (3/5) – A serious one

A serious one this time, please, please, please, for your own sakes - always, always wear a seatbelt.

Advice given to me as a child (2/5) – Think before you open your mouth

Saying stupid things is a habit I’ve never properly grown out of. When I was young, my Dad was forever telling me to think before I opened my mouth. Here’s when someone really should have taken on board what he said.

On the rota, I’m down to do a gynaecology list in the afternoon with one of the consultants. On the list is Mrs Hughes, a middle-aged professional woman, who is rather nervous about the whole thing. During my pre-op assessment, it becomes obvious to me that this woman I petrified of having a general anaesthetic – so much so that she is considering just getting up and leaving the hospital. When I probe a bit more into her fears, it turns out that she’s not really that bothered by the idea of the surgery but is really scared of the unconsciousness that general anaesthesia necessitates.

I explain this to the consultant and the consultant comes to see the patient. After a bit of discussion, Mrs Hughes agrees to have her operation done under spinal anaesthetic. This means that she gets an injection into her back to give adequate pain relief for surgery to continue, but she’ll remain totally awake and conscious throughout the whole operation.

It’s now later on and we’ve done the spinal anaesthetic. Mrs Hughes is in the operating theatre and the consultant gynaecologist is part way through the operation. Mrs Hughes is perfectly calm, so we haven’t given her any sedation at all and I’m just chatting to her about this and that - so far so good.

At this point, the theatre doors open and one of the particularly loud theatre nurses walks into the room. She’s been working in the theatre next door and has come in to get some piece of equipment they need.

She spies the surgeon and in a loud voice exclaims, “Hello again David! It seems that these days, every time I see you, you’ve got your hand up some woman’s fanny!”

There are lots of shocked/embarrassed faces in the operating theatre and a deathly silence until my consultant pipes up with, “Errrr, Mary, this is a spinal. She’s totally awake.”

“Oh, shit” comes the reply from said theatre nurse who promptly legs it back out of the room.

Luckily, Mrs Hughes saw the funny side.

Advice given to me as a child (1/5) - Don't run in corridors

As a child, I was seemed to be always being told what to do by various grown ups. My parents, my teachers, my aunts and elder sibling all seemed to take great delight in giving me advice/bossing me around. “Go back upstairs and comb you hair properly,” “Tidy your room,” “Don’t leave your homework to the last minute” they would tell me and, being the good boy that I was I’d (usually) comply.

As I’ve grown older, I’ve realised that some of the time, their advice had some reasonable basis behind it and since I’ve been a doctor, there have been occasions when I look back and think “I really should have listened to what my Mum said.” Here are some of those occasions.

Don’t run in corridors.

-A favourite of various teachers at my primary school.

I’m on call for anaesthetics when the crash pager goes off.

“...Cardiac arrest; renal unit.
Cardiac arrest; renal unit.
Cardiac arrest; renal unit...”

I’m with the consultant in theatre and she says that I should go while she looks after the patient on the table. The renal unit is a fair way away from the operating theatres and I’m feeling quite sprightly, so I decide to run to this crash call. Running through the hospital is all a bit “E.R” and it’s not visiting times so the corridors are relatively empty.

I pick up speed as I enter a long corridor with a T-junction at the end of it and muse to myself that I’ll probably get there before the medical team (which is not the way it normally is). I’m getting closer now, but as I round the corner of the T-junction, out of the corner of my eye I glimpse somebody running from the other direction. It’s the medical FY1 doctor, who’s been pelting down the other corridor to get to crash call. I try to avoid her, but it’s too late and we run smack-bang into each other. Because I’m quite a bit larger than she is, I knock her flying to the ground and then sort of trip over her.

Worse, we are near the canteen and I fall into a stack of used breakfast trays and we both end up in a heap at the bottom of it. As I hit the stack of trays, manage to tip a tray containing some uneaten porridge and cold tea over both of us.

Luckily neither of us were hurt apart from a little bruising, but we did get some funny looks from the nurses and the rest of the crash team when the two of us arrived with me with porridge on my scrubs and her with tea dripping from her hair.

Anatomy of a night shift

The tagline under the title of my blog says “Diary of a junior doctor.” I feel that, currently this is a bit of a misnomer because since I started, this blog at no point have I written a “diary” of what I actually get up to. I’m going to attempt to rectify this situation with four posts that detail what I, an anaesthetist in training, actually do with myself all day (and it’s a bit more than sitting reading the paper).

Anatomy of a night shift

19:45

It’s dark and it’s raining. I’m in my car driving towards the hospital to do another night shift. I’m actually feeling pretty good. Hands-free mobile technology has allowed me to spend much of my journey chatting to my girlfriend. I pull into the hospital car park and have enough time to grab a coffee, and get changed into my scrubs before the shift starts at 8. As the anaesthetic SHO on-call, my most important duty is to keep the Emergency Surgery (CEPOD) Theatre going so all the patients who need operating on that day have their operations. Sometimes, there’s an operation going on as I start my shift, sometimes there isn’t. I wonder what’s happening in theatre at the moment

20:00

There is indeed an operation going on. I walk into the operating theatre and say hello to Melanie, the anaesthetic SHO on-call for days. We exchange pleasantries about how her shift has been (frustratingly slow) and she tells me about the patient. Surgery has just started on a fit, healthy 4 year-old girl who had split her lip open and the Maxillo-Facial surgeons were just going to sew it up again. There were a couple of other people on the list for surgery tonight, one 12 year-old for an appendicectomy and one 71 year-old with a broken leg that needed fixing. I get a handover from Mel about the child on the table, take hold of the breathing circuit and Mel goes home.

The Max-Fax surgeons were true to their word, the operation doesn’t take long at all. When they finish, I turn of the anaesthetic vapours, turn up the oxygen and wake the little girl up.

20:20

I’m in the recovery area and I’m satisfied that the girl is awake, comfortable and breathing for herself. One of the theatre nurses comes up to me and asks, “Can we go and get the next patient now?”

“No,” I reply. “I haven’t seen this boy yet.”
“Can’t you just see him in the anaesthetic room?”
“No. I’ll see him on the ward.”

Personally, I think that people should be given the opportunity to speak to the anaesthetist before they come down to theatre. Also, my seeing the boy on the ward gives me to pick up any problems that the surgeons may have missed/ignored and potentially do something about them before the operation.

I trek across to the children’s ward and meet young Joe who is lying in bed with his mother beside him. Joe is actually quite sick. He’s had belly pain for two days now and he has a fever of 39.1˚C, his heart is racing and he’s very still and quiet, the way children get when they feel really rough. I do my pre-op assessment and then I tell Joe and his Mum what to expect when they come down to theatre. Joe has lots of questions about exactly how I’m going to keep him asleep and I spend a bit more time explaining how anaesthesia works and reassuring him a bit.

I let the paediatric nurse looking after Joe that someone will be up to collect him quite soon and then head back to theatres via the Intensive Care Unit. I find the anaesthetic specialist registrar (SpR) – my immediate senior. It’s VJ tonight. He already knows there’s a child booked for theatre. He asks me if I’m happy to carry on with the case alone. I tell him that I am and head off back to theatre.

21:10

Joe and his mother arrive in the anaesthetic room. I’ve got everything prepared and I set about getting Joe anaesthetised. He’s been sick earlier, so I plan to do a “crash induction” and intubate him. Crash inductions (or Rapid-Sequence Inductions) can be quite fraught with danger, especially in unwell patients and especially in youngsters. I’m aware that I’m all alone so I make doubly sure that everything is ready and everything I may need is to hand. It’s not a problem though. I safely get Joe anaesthetised and intubated and the nurse takes his Mum away to have a coffee.

The operation takes a while because the surgical reg is teaching the surgical SHO. About half an hour into surgery, my pager goes off.

“Could you attend A&E resus IMMEDIATELY please. Airway problem.
Could you attend A&E resus IMMEDIATELY please. Airway problem.
Could you attend A&E resus IMMEDIATELY please. Airway problem.”

There’s no way I’m leaving this anaesthetised, intubated, ventilated child to go to A&E resus so I ask one of the theatre assistants to phone switchboard and get them to page VJ, the night anaesthetic SpR on-call, as I am unable to attend.

22:45

The operation is all over. Joe had a nasty, perforated appendix but now it’s been removed he should start to get better. I waken him in recovery and he’s comfortable, if a little tired.

Emily, the ODP on nights asks me what I’m going to do about the last patient on the list – the man with the broken leg. I tell her that I’m going to check what’s going on in A&E and speak to VJ, and then I’ll get back to her.

22:50

A&E resus is empty. I figure that if it was an airway problem, then the patient may well be in the CT scanner so I walk round to radiology. I’m proven right. There’s a clutch of people in the observation room of the CT scanner. VJ has intubated and sedated the patient and a quick glance at the screen tells me that whoever the patient is, they have a significant amount of bleeding inside their skull. Bad news.

On the return journey to A&E resus, VJ fills me in with the story of what happened. Basically, the patient is a 25-year-old man found semi-conscious by his housemate when she got home from work. VJ had done a great job in stabilising the patient regarding blood pressure, sedation, monitoring, carbon-dioxide levels, oxygenation and ventilation etc… etc… There’s more to do though, and I give him a hand as the A&E doctors get on the phone to the neurosurgeons at TheBigTeachingHospitalDownTheMotorway.

The brain surgeons listen to the history, review the CT scan results and agree that this man needs emergency brain surgery tonight.

“I’m going on a journey, aren’t I?” I ask VJ
“Looks like it,” he replies. “Have you done inter-hospital transfers before?”
“No.”
“OK, well there’s a few things that you’ll need to be careful of…” says VJ, and then proceeds to give me a five-minute crash course on how I should transfer this patient.

I’m not actually all that concerned. The patient, Jimmy his name is, is pretty stable from a cardio-respiratory point of view. I just make sure that my monitors are working, I have the drugs I may need in my pocket and that all my equipment is present and in working order. I also make sure I take my coat, some money, my mobile phone and my sandwiches.

00:15

The ambulance crew are here and we load Jimmy into the back of the ambulance. Emily, the ODP, and I squeeze into the back and the two ambulance crew hop into the front, turn on the blue lights and off we go.

The journey itself is pretty uneventful. I have to play with Jimmy’s arterial line a few times to get it to keep working. I also notice that when we’re on a bumpy part of the road, the ECG monitor does a good impression of VF, which was initially quite disconcerting.

During the journey, I start to feel tired. I wish I’d had a coffee before we left, but Emily and I share my sandwiches and this helps keep us going.

When we arrive at TheBigTeachingHospitalDownTheMotorway, we go into A&E resus. Straight away, TheBigTeachingHospitalDownTheMotorway’s nursing and medical staff are surrounding us asking questions and organising various things. I give two handovers, initially to the A&E SpR and then to the consultant anaesthetist who has come to take the patient to theatre. I have to say, having so many people who I don’t know doing stuff all at the same time is really distracting. I have to really concentrate on ensuring that in the midst of the milieu, we are still breathing for Jimmy and looking after him. He goes to theatres pretty quickly though and Emily and I hop back into the back of the ambulance for the journey home.

02:40

We arrive back at my hospital. I really am feeling quite shattered at this point, so I go and get myself a coffee. I really do believe that after midnight, the NHS runs on caffeine. I go and find VJ and get my pager off him.

He’s on the High Dependency Unit (HDU) and we have a quick debrief about my journey to TheBigTeachingHospitalDownTheMotorway. Our chatter is cut short by the sound of his pager going off. It’s the medical registrar with a referral for us from A&E.

02:45

VJ and I arrive in A&E and get the full story from the med reg about his patient, Mr Singh. Basically it’s a middle aged man with very severe, community acquired pneumonia. We go and review the patient along with the results of the investigations the medics have done. VJ ummms and aaaahs for a bit about whether or not to accept the patient onto the HDU. Eventually he decides to accept him and he explains his rationale to me.

“Basically, Michael, this man is on the borderline. As he is right now, he would probably be alright on a normal ward – just. My concern about him is his oxygenation. His pO2 is only 15 despite breathing high flow oxygen via a rebreathe mask. If he gets any worse than he is at the moment, then we’d probably have to intubate and ventilate him and it’d take forever to get him off the ventilator. If we accept him now, give him some CPAP and lots of chest physiotherapy, we may help him turn the corner and avoid intubation.”

We discuss things with the med reg, add a few things to his management plan, call in the physiotherapists and ask the nurses to transfer him to HDU as soon as they can.

03:40

Mr Singh arrives onto HDU. The nurses do their admission and the physiotherapist does some chest physio with him with moderate success.

VJ finishes writing up the admission notes and then turns to me and says, “I might go and try and get my head down for a bit, are you alright to put in an arterial line by yourself?” I tell him that I am and he leaves the unit.

The nurses had kindly put together an arterial line, “A-line,” trolley for me and I go to Mr Singh’s bedside and explain what I’m about to do. The last three A-lines that I have done have all gone in like love’s lost dream, so I’m pretty confident I’ll be able to site one into Mr Singh. The one I did last week went in so easily that the attractive-married-but-still-very-flirty A&E nurse remarked, “Wow! Well done! You are really good at those!”

Unfortunately, my confidence is misplaced in this case. Maybe it’s because of his tachycardia, maybe it’s because it’s the middle of the night and I’m tired, but I find it a real struggle. I try once and get a flashback but the catheter refuses to advance. I try again and manage to kink the tube. I always use large amounts of local anaesthetic when doing these, so Mr Singh is not at all bothered by me poking around his radial artery with a big needle. I don’t seem to be able to feel a radial artery pulse at all on the other side so I try a third time on the same side. “One last try,” I tell myself but it’s no good. I get a flashback again but once again, I can’t get the catheter to advance. I’m getting really frustrated as I’ve been trying to get this sodding line in for nearly an hour now. I consider trying a different site- perhaps the brachial artery or the dorsalis pedis, but, on balance I decide to keep my promise and I give up.

I tidy away the A-line trolley, go to the phone and bleep VJ to come back and help me out. He comes back to the unit and uses the ultrasound machine (why didn’t I think of that?) to gently coax the A-line into Mr Singh’s radial artery. VJ is a great reg to be on with and he gives me a quick 101 in how to use the ultrasound machine and the best tricks for locating the ulnar, median and radial nerves in the forearm using ultrasound.

05:30

Our little teaching session is interrupted by one of the ICU nurses asking us to come and have a look at her patient because she’s rather concerned about him. The patient is question had had a long maxillo-facial operation and reconstruction for cancer. We were using a drug (metaraminol) to keep his blood pressure up, but, the same drug was causing his heart to beat worryingly slowly. Said nurse had turned off the metaraminol pump and asked us to come and review.
VJ had had a handover of all the patients in Intensive Care at the start of his shift and was pretty au fait with this gentleman’s problems. He turned the drug back on again and gave the nurse explicit advice about which drugs to give if his heart rate fell below 40 beats per minute. As we leave his bedside, it occurs to me that this big man with scars and staples across his face looks not too dissimilar to Frankenstein.

05:45

We go back to HDU to see how Mr Singh is doing. He’s tolerating the CPAP well and he tells us that he’s feeling slightly better and is breathing slightly easier. His blood gas shows and improvement too. Satisfied, we leave him to get some rest.

06:00

There’s nothing really pressing for me to do now and I’m feeling really exhausted. I’m wary that I’ll have to drive home at the end of my shift so I head off to try and get a little sleep. Doctor’s working patterns have changed from “on call” to full shifts. This means that we are meant to be working all the time we are present in the hospital. Hospital management have therefore taken the “on-call rooms” away from junior doctors. This means that when your night shift does get quiet, there are no beds to sleep in. Junior doctors do still have the Doctor’s Mess thought and this is where we all go to try and grab a little shut eye.

I enter the mess and all the lights are off. The large sofa is occupied by the Obs & Gynae house officer who is snuggled up with someone I’ve not met before. Judging by his snores, I doubt there is any hanky-panky going on. The surgical SHO is sprawled out on one of the small sofas. The surgeons always seem to be in the mess during the night – this is mainly because we anaesthetists keep telling them that they’re not allowed to operate through the night unless it’s life or limb saving surgery. Fortunately for me, the other small sofa is free and I curl up and quickly nod off to sleep.

07:05

I’m awoken about an hour later by a pager going off. I come out of my daze and realise that it’s not my pager, but that of the Obs & Gynae house officer. She gets up, gives whoever she was sharing the sofa with a quick kiss and leaves the mess.
I decide that I’d better get up anyway and wander back to the Intensive Care Unit. VJ is there reviewing all the patients ahead of the morning handover to the day team. I have a look at Mr Singh. He’s sleeping. His latest arterial blood gas shows that he is continuing to improve. I very much doubt that he’ll need a ventilator now and I hope that he’ll be well enough to go to a normal ward within the next 24-48 hours.

Coffee in hand, I go up to the anaesthetic office and fill in my form for some annual leave over the Christmas period and leave a note for the anaesthetic secretary regarding a query I have over the rota.

08:15

My shift is over. I meet Mel, who has just arrived for another day shift. I tell her briefly how my night was and then she goes to work seeing the patients booked on the morning’s Emergency Surgery list. I leave the hospital main entrance and head towards the car park. As I walk I smile because I know that soon, I’ll be fast asleep in my own bed.

Stupidity

Occasionally you hear about something that is just so stupid that it takes your breath away. 13-year-old Hannah Jones has spent much of her life in and out of hospital as she’s had leukaemia. Her heart is now failing and she has been offered a heart transplant. Hannah, however, has had enough.

She knows that the heart transplant may or may not be successful. Even if it is successful, she knows she’ll probably need another one before the end of her teenage years. She knows that the anti-rejection drugs that she’ll have to take after the operation carry a significant risk bringing her leukaemia back and she knows full well the pain and suffering that lies down that particular road. On balance, Hannah, with the support of her parents said, “No, thank-you. Let me be. If I am to die, I’m going to enjoy the rest of my days rather than spend them in a hospital bed.”

So far, this is another of those sad stories that you come across from time to time if you work in a hospital. However, somebody in the Primary Care Trust didn’t like Hannah’s decision. Somebody thought that she shouldn’t have the right to decide what was going to happen to her own body. As a result, Hannah was threatened with being taken away from her parents into care and forced to have the operation against her will.

It’s really unbelievable. The courts have seen good sense and have respected Hannah’s decision, but all the hassle and anguish that comes with a court case could have been avoided if people had just listened to Hannah in the first place. After all, isn’t that what the NHS is supposed to be about? Listening to our patients and making their care our first concern?

The mind boggles.

I need a hero

If I look back at my time through medical school and so far as a junior doctor, there have been a string of people in the medical profession that I’ve really looked up to and admired. I’ve had the good fortune to work with some unbelievably intelligent, caring, hard-working people and I think I’ll be forever grateful for the little tips and all the advice they’ve given me. I’m not just talking about direct clinical care, but about all the other things that come with being a doctor such as practical tips, emotional support, and sometimes just sticking up for you when others are trying to pull you down.

I now firmly believe that having good role models has been, and still is crucial to my training so far as a doctor. Don’t get me wrong, I’m not saying that every doctor is to be admired – I’ve come across my fair share of arseholes with a medical degree, but, like having good teachers, you never forget the good doctors you’ve worked with in the past.

At my current hospital, I’ve worked a few times with Dr Harrison who is a rather large lady from Barbados. I have to say I love her to pieces. Not in a romantic way, but I really admire the way she works. She’s a fantastic anaesthetist and she has taught me loads about working with children, about nerve blocks, about vascular access and about anaesthesia in general. But it’s much more than that. I really respect her manner, her patience, the fact that she obviously really cares about what she does and about the people she works with, her good humour and general good nature.

Maybe I’m a bit prone to hero-worship, but when you work with people as fantastic as Dr Harrison, I think the admiration is well deserved and I do actually find myself saying to myself, “One day, I want to be like you.”

In which I'm left flabbergasted

I’m on the ward seeing patients before the morning’s general surgical list and the next patient is Mr Barnes, a 52-year-old man who’s come in to have his hernia repaired.

“…Mr Barnes, aside from the problem with the hernia, do you have any other medical problems?”

“Yes, I’ve had lung cancer.”

“Lung cancer?”

“That’s right doc.”

“Is it still a problem for you?”

“No doc, I’ve had it treated and they tell me it’s gone away.”

“Right… What treatment have you had?”

“I had radiotherapy and chemotherapy for a few months last year.”

“And do you still see the cancer doctors”

“Yes, I saw him about three months ago, but he said that it’s in remission and there’s no need to do anything else about it.”

A bit later on

“Do you smoke sir?”

“Yeah.”

“How much?”

“When I try to cut down, about ten a day, but I’m smoking about twenty a day at the moment.”

………………………………………………………………………..

I really, really don’t understand some people. I’ve tried to get my head around it but I really can’t fathom where Mr Barnes is coming from.

I know that some people find giving up smoking really hard, but this is totally ridiculous. I could have understood Mr Barnes’ smoking more if he had terminal cancer and he’d said something like “I’m going to die anyway, so there’s no point in stopping now – it’s too late for that.” But he doesn’t have terminal cancer. His cancer is in remission.

Chemotherapy and radiotherapy is horrible ordeal to have to go through. It’s months of feeling awful, feeling weak, feeling sick, not to mention the emotional strain it puts on you and the people around. Why on earth would anybody put themselves through all that and then continue to smoke afterwards?!? So he can go through it all again in a couple of years’ time with his brand new cancer?

Mr Barnes is one of the lucky ones. He’s one of the few that actually get batter from their cancer and didn’t die along the way. He’s one of the people that we in the medical profession talk about when we say “To see Mr Barnes walk out of hospital for the last time after all those months of heartache, knowing that he’s actually got better, makes it all worthwhile you know. For all those that don’t make it, it makes it means so much to see somebody come through it.”

But Mr Barnes continues to smoke. He continues to spend his money on those little white sticks that gave him the cancer in the first place. In the not-too-distant-future, he’ll return to hospital either with a recurrence of his old cancer or with a new cancer and we’ll have to try and make him better again. What on earth is the point?

Sometimes I don’t know why we bother. This strikes particular chords at a time when there’s so much debate about top-up payments for cancer treatments because the NHS can’t afford to pay for everybody. If patients like Clive Stone really want to know why the NHS can’t afford to pay for their treatment, they should just pop in and have a word with people like Mr Barnes.

That’s where all the money’s gone.

Saturday Night

Things a 16-year-old girl should be doing at 9pm on a Saturday night.

• Voting for her favourite person to win X-Factor
• Arguing with her parents who tell her “You are NOT going out dressed like that.”
• Chatting with her mates and explaining why her new boyfriend is so fantastic
• Posting pictures of her cat on Flickr
• Downloading the new Kings of Leon song
• Getting excited as she sits in the cinema and the opening credits of High School Musical 3 come on the screen
• Chatting to her Irish friend on Bebo
• Standing nervously in the queue to get into the new bar in town and hoping the bouncers don’t spot her fake I.D.

Things a 16-year-old girl should NOT be doing at 9pm on a Saturday night.

• Lying cold and lifeless on an A&E trolley as the priest reads her last rites.

Through the darkness

I’ve been working as a doctor for a few years now which means that I’ve a few years of working night shifts. You’d think that after all this time I’d know the best way to re-adjust my body clock so I can work through the hours of darkness but this is really not the case.

The trouble with working all through the night is that you invariably end up deprived of sleep, no matter how hard you try to sleep during the day. On top of that, it’s actually pretty difficult to eat properly. You don’t really feel hungry when you’re on nights, but a couple of nights in, you’ll start to feel really weak, irritable and spaced out and you’ll realise that it’s probably because you hardly eaten anything for 48 hours.

I’ve tried various strategies to get me through. I’ve tried forcing myself to stay awake the night before, I’ve tried trying to sleep whenever possible, I’ve tried sugar, I’ve tried caffeine, I’ve tried exercise and I’ve come to the conclusion that there is no good way to flip your body clock to working nights and then flip it back again.

My current strategy is to eat two largish meals – one before I set off for work in the evening and one before I leave work in the morning. I’ll also try and eat something at around 01:00 and if it gets quiet, I’ll try and snatch some sleep. I don’t think getting through nights becomes any easier, but I would say that these days, I’m more prepared for how crap I’ll feel.

On a roll

Now I’ve passed my exam, it means that I’m going to be an anaesthetic registrar in less than a year’s time. This means that out-of-hours I’ll be the most senior anaesthetist in the hospital and have to look after just about everything with no immediate back-up. It’s quite a scary prospect, so for the next few months I’ve decided to try and get as much exposure as I can in the aspects of anaesthesia and intensive care that I feel I don’t have much experience in. Effectively this is just about everything at the moment, but right now I’m trying to concentrate on specific procedural skills, so I’ll feel much more willing to do things out of hours. Specifically, I’m focusing on spinal and epidural anaesthesia.

This is one of the many aspects of anaesthesia that I find truly amazing. Basically, with an injection in the back, patients can have their operations and be completely awake and lucid throughout. You can sit next to them and have a conversation about gardening whilst they have their leg sawed off or their womb sliced open and they are completely pain-free throughout the whole operation. It’s really quite incredible if you think about it.

I know this link makes it look very simple but actually giving the injection into the right place is very tricky though because you can’t see where your needle is going. I have to rely on my knowledge of anatomy and previous experience to get it right.

A while ago, I posted about having a bit of a crisis of confidence. I basically felt that I wasn’t as good as I’d have liked to be at some aspect of my job. Well, it’s now a month later and I feel rather different, I've got over myself a bit and now just want to get as much experience I can at stuff so I can get better at it.

I clearly remember being a house officer in my first few months of my medical job. We had an elderly gentleman, Mr B., on the ward who had terminal cancer. He needed a venflon so we could give him some IV fluids to prevent him getting dehydrated. I tried once; I failed. I tried again; I failed. I must have looked really dispondent because he said to me, "Son, if you fall of a horse, the first thing you must do is get back on it again." The third time, I succeeded in getting a venflon in. Unfortunately, Mr B died of his cancer a couple of weeks later, but his words have stayed with me to this day.

A couple of months ago, I often just could not do spinal anaesthetics. I’d attempt and fail and then have to ask the consultant or registrar to take over. In the last few weeks, however, I’ve got much better at it. All of my last five attempts have been successful. All five patients had no pain for their operation whilst being awake. I’m on a bit of a roll and am feeling a bit pleased with myself at the moment.

On another note, I feel that my getting the exam out of the way early is going to be really beneficial for me. Now, I really do feel like all the pressure is off and I can get on with the business of learning to be a really good anaesthetist. Also, from a career point of view, it gives me time to get involved with audits and teaching. This is good because I really enjoy teaching and it will look good on my CV. All-in-all I feel that for the next few months, at work I can relax a bit and really start to enjoy myself.

A shot in the arm

For those of us who work in the NHS, it’s something that divides opinions as neatly and effortlessly as Bob Dylan or Marmite. It comes around at roughly this time every year and the chatter I hear around the wards and operating theatres suggest that this year is no different. You hear snatched snippets of conversation that go like…

“Are you going to do it? I’m not sure if I should I know Adrian’s doing it but he’s a bit older than me”

“There’s no way that I’m going to do it – I don’t see the point and I’ll just feel rough afterwards.”

“The way I see it is that it’s there to help us so we may as well take the opportunity while it’s there.”

“I can’t believe you’re going to do it, why on earth would anyone want to do that to themselves?”

I’m talking, of course, about the annual flu jab. This gets offered around this time of year to all health care workers as we are deemed “at high risk” because of our exposure to sick people. There is a problem though. The flu vaccine will inevitably make you feel really rough for a couple of days. You’ll get a runny nose, a cough, achy joints – in short, you’ll feel just like you’ve got the flu. It’s not as bad as the real thing though. I remember one Christmas when I was in my mid teens and I came down with the flu really badly. It was horrible. I literally couldn’t get out of bed for a couple of days and I felt hideous for about a week.

As a result, I see things like this: actually getting the flu is far worse than feeling rough for a couple of days. If the shot in the arm helps prevent me from the misery of the virus, then I’m all for it.

Needless to say, I was at the front of the queue when the Occupational Health Department opened their doors today.

200

I would like to say a huge thank-you for your messages of congratulations on my last post.

You know, I went into the city centre on Sunday afternoon. I took the bus in and I walked around for a bit. Not for any reason in particular, just because I could. I really feel that there has been a huge weight lifted from my shoulders. I was actually laughing to myself when I was walking through the park. I was laughing because I didn’t have to go home and try and remember the breakdown products of sevoflurane or the pKa of fentanyl or anything like that. What felt even better was that I didn’t feel guilty about not studying and didn’t get stressed that this was time I was wasting in which I could be learning those crucial few factoids that could make the difference between a pass and a fail. It felt great.

This is my 200th post on this blog.

I started this blog back in spring 2007 (halcyon days according to the politicians and financial experts, though I think several thousand junior doctors would disagree) and I honestly didn’t think that I’d still be doing it a year and a half later. There was no political motivation behind the blog (there still isn’t), I just started to write because I enjoyed writing for writing’s sake. I still do enjoy writing, and I guess, I’ll keep blogging as long as it’s fun for me.

Back when I started, I wasn’t to know just how spectacularly I’d be dicked around by MMC and I was probably pretty keen to continue working in general medicine, but had started to think seriously about switching to anaesthetics. My life has changed a hell of a lot since I started this blog (generally for the better, I think) and I think I’ve changed rather a lot as a person too.

I’m clearer about what I want from my career and my life in general. I’m less willing to be pushed around by others who want to make their own lives easier. I’m also much less scared now. I’m less scared by what I could potentially be asked to deal with. When I first qualified as a doctor, we used to joke about the tag line from the old Dr Pepper ads – “What’s the worst that could happen?” because we were really scared about being harming our patients or being powerless to prevent their demise.

Now, after being an anaesthetic SHO for a while now, I’ve seen “the worst thing that could happen” again and again and again. I’ve seen people vomit blood and keep on vomiting until they die because they literally have no blood left. I’ve a little girl rushed into A&E but amid the drama and the frantic activity, there is one unchanging fact – the baby is dead. I’ve seen people with the most horrific injuries from accidents (including a partial decapitation) and every time something this awful happens, I’ve seen the hospital staff try to move heaven and earth to help these people who come to our door. The point is, I’ve had to cope with it and I have to try and be of some use to these people. Every time the on call pager goes off and I get the “Could you please attend A&E resus immediately” I know that “the worst that could happen” is probably already happening and they’re calling me to help them out.

This post seems to have turned a bit more introspective than I intended it to. Being a doctor isn’t all doom and gloom and blood and guts – it’s actually quite fun. I enjoy chatting to the patients and the staff every day. I enjoy feeling that there are a number of people walking around the UK right now whose life is better in some way because of something I’ve done. I enjoy feeling that every day I make a difference sometimes in a big way, but more often in a small way.

I may bitch and moan about things that frustrate me about my work but, at the end of the day, I love my job and, all-in-all, I wouldn’t really want to do anything else.

Anyway, enough blabbing, I’m off to bed – I’m on call again tomorrow.

Results Day 2

Friday 12:48
I’m sitting having lunch with a couple of the other doctors that I work with.

“What time do you find out if you’ve passed?” Helen says to me
I look at my watch for the hundredth time. “In seventy-two minutes.” I reply
“I can’t believe you’re so calm about it. I’m really nervous about your results and I didn’t even sit the exam!”
“I’m not actually that calm about it at all, I’m just forcing myself to not think about it.”
“I’m sure you’ll be fine though – I have faith.”
“Thanks, but we shall see. It’s like VJ was saying earlier, I think with this exam, the first attempt has to be the best one. If I fail, I’ll have to do it again in January and the thought of having to do all that revision again is one of the most depressing feelings in the world.”
“And then there’s all the money that you paid to sit the exam in the first place,” adds VJ
“Yes, that as well,” I reply. “And also there’s the pride as well. I’ve made such a flipping song and dance about doing this exam that if I have to go round and tell everyone that I’ve failed, it’ll be just so embarrassing.”
“I wouldn’t worry about that,” reassures Helen, “not many people pass this exam first time, we’re just keeping everything crossed for you.”
“Cheers,” I mumble. “I appreciate that.”

Friday 14:00
I’ve started the afternoon gynaecology list with one of the consultants.

“Do you mind if I go see if the results are up?” I ask.
“Of course not, you go ahead.” I head towards the theatre doors and he says, “Michael, when you come back, I expect you to be smiling.”

I walk round towards the staff room where the computers are. I wasn’t really calm earlier on. I’ve been bricking it all day and now my heart is hammering in my chest and I’m absolutely petrified. I enter the password that allows me to access the internet at work and type in the web address for the Royal College of Anaesthetists. I find the results page and click the link you download the .pdf file containing the pass list.

I slowly scroll down to where my number ought to be. I remember doing this last time, but had forgotten just how horrible the moments just before you find out your result are. This time, I’d remembered my number off by heart so I knew exactly where it ought to be.

My number was up.

I’d passed.

It felt different this time. I didn’t shout or punch the air. I felt a huge wave of relief sweep over me. I sank my head into my hands and had to take a few big breaths. I’d worked so hard for so long and now it was all over. I couldn’t believe it was all over. I’d done it. I’d achieved what I set out to do. I’d done what so many people had failed to do and what so many people doubted I could do. I’d passed the FRCA primary at the first attempt, six months ahead of schedule. I think at this point I may have even shed a tear.

Then I started to smile and then to laugh and then to laugh even more. I stood up with a huge smile on my face and went off to let everyone know that I’d passed.

--------------------------------------------------------------------------------------

I’d also like to say a huge thank-you to everyone who wished me luck online. Just before the exam I really did feel like everyone, I mean everyone - family, friends, work colleagues and commentors on this blog - was rooting for me and I think knowing that really helped me on when the exam got really tough.

Thank-you

Leaving everything on the track

So this is it.

My bags are packed, my shoes are polished and soon I’ll be heading off to the capital to sit the second part of the FRCA Primary exam. Two oral exams and one 90-minute OSCE stand between me and the “pass” that I need to go on to become an anaesthetics registrar (or ST3 in new money).

I have to say that I’m not feeling too frightened or nervous by the prospect of having my knowledge picked apart by the RCoA examiners. I’ve been working incredibly hard over the last couple of weeks and to be honest with you, I’m REALLY fed up with it all. I’m sick of the sight of my textbooks and I can’t wait for it to all be over – for better or for worse.

With this exam I’ve realised that I’m not going to be able to know everything that they could possibly ask. I reckon that you could spend half a lifetime studying physiology and still get flummoxed by a question on some random cytokine and same applies to pharmacology. My simple aim has been to try and know enough about enough subjects to pass this exam. I have to say that I’m feeling quietly confident about it at the moment and I reckon that if I manage to keep my composure (easier said than done!), with a little bit of luck I should hopefully be OK. Of course, I’m just speculating – I won’t really know this until the results are published at 2pm on Friday.

I remember watching the Usain Bolt breaking the legendary Michael Johnson’s 200m world record in the summer and in an interview afterwards he said something really telling.

“The night before that 200 metres final I told my room-mate,
Maurice Smith, ‘I'm going to leave everything out there on the track
tomorrow,'”

He “left everything on the track.” He gave it his all and didn’t hold anything back at all.

In some ways I too feel I’m giving this exam my very best shot. I’ve used all my study leave and I’ve racked up over 100 hours of study in the last three weeks alone. I’ve really tried my hardest to cram as much as I can into my skull, but despite this I’m all to aware that there is a hell of a lot that I still don’t know. I’m going to give this my very best effort and I hope that it will be good enough.

The problem with “leaving everything on the track” is that I don’t know what I’ll do if I fail this exam. Like I say, I could hardly have worked harder for it, so failure kind of leaves me with nowhere left to go. But I’m not really contemplating failure at the moment to be honest, the prospect of having to pick myself up and put myself through all this again makes me feel physically ill. I’m not really into rap music but I think Eminem spoke volumes on “Lose Yourself” when he said “…success is my only motherfucking option – failure’s not…”

Whatever happens, I shall be glad when it’s all over.

No such thing as a free lunch

Back near the start of the year, I was feeling a little poor. Like a lot of people, I’d ended up being a little overgenerous at Christmastime, and I started the new year feeling a tad broke. One morning, I noticed a poster saying there was a free lunch for junior doctors that day in the doctor’s mess. I’m all in for a bit of free food, so I made sure I was in the mess at 12:30 to tuck into the M&S sandwiches.

The lunch was sponsored by one of these Independent Financial Advice (IFA) companies. This meant that, while we munched away, we had to listen to their reps talk to us about the state of our finances and what we needed to do to “help secure our financial future.” I’d heard similar things from similar companies several times since my med student days and I’d become rather cynical about what these people say.

Basically they bang on for about 20 minutes telling us loads of stuff we know already, then they start talking about how expensive university/mortgages/living costs are and then they try and flog us payment protection insurance. Daniel and Jane, the IFA reps, were no different. They were very charming, very attractive, wore nice suits and had expensive-looking haircuts and I could see how you could get swept along with all the “wise” words that they were saying.

Like I say, I was feeling a bit broke at the time and I was a bit more willing than normal to listen to any advice about how to make the money I earn go a little further. I booked an appointment and with Daniel a week or so later to discuss the state of my finances. I’ve heard for a long time from many sources that “over the long-term shares are a better investment that property” so I was quite interested in how the whole “investing in the stock-market” thing worked. Daniel and I met and I batted away his hard-sell of payment protection insurance and then I had a look at the share portfolio that he had put together for me.

He said that he’d selected “the investment funds that most suited my ambitions” and gave me a lovely portfolio containing lots of nice graphs and lots of stuff like “MultiPEP” and “+113%” and “convenient and tax-efficient way of investing” and there were lots of pages with lots of names and lots of numbers in very small print.

It all looked very impressive, but my problem was I still had no bleeding idea how it all worked. As far as I could see, the deal amounted to me giving Daniel £50 to £100 each month and then I may or may not get more or less money back at some point in the future… perhaps. I really didn’t “get” how investing in shares worked, so I was a little loathe to put my hard-earned money into something I really didn’t understand.

I have a few friends who work in the financial markets and when I meet them they seem to be very successful but when they start talking about “P&L accounts” and “asset ratios” I get lost very quickly. I’m sure it’s not actually that complicated, but I’m basically not at all interested in it, so I either tune out very quickly or change the subject back to women and football.

Anyway, the long and the short of it is that I didn’t buy any shares and put my £50 each month into an ISA instead. To his credit, Daniel agreed that that was probably the wisest idea at the time.

Fast-forward now to last Thursday evening. It’s about 18:30 and I’m just arriving home from work. I look around my place and it’s an absolute tip. I will confess that I have a tendency to go to seed a bit when I have a big exam coming up but I decide enough is enough and dedicate the rest of the evening to tidying up. Guess what I find? Yup, the share portfolio that Daniel put together for me all those months ago.

I’ve been following what’s been happening in the financial markets with a dispassionate interest (I want everyone who feels sorry for the city bankers to put their hands up now… anyone?... anyone at all?.... I thought not) so I thought I’d look on the internet about what happened to the funds that Daniel had advised me to invest in.

Guess what? Every single one of them was down by between 15% and 40% over the last year. If you include Daniel taking his fee and the fund managers and taxmen taking their cuts I would have been left significantly out of pocket. Now despite what you hear in the press, I don’t actually earn a vast amount of money and I would have been seriously pissed off if I’d decided to invest at the start of the year, especially knowing that my money had probably been spent by City Boys pouring Kristal over stripper’s arses in some lapdancing club in Soho.

Now, from what I understand, banks like Northern cRock, Lehman Bros and HBOS got themselves into trouble basically by investing in thing they don’t understand and as I sit here typing this, I feel like patting myself on the back for not making the same mistake that they did.

The other point I want to make is that it is Daniel’s job to pick the best places for me to invest my money. I have no idea if he’s still doing that job and I have nothing personal against the guy, he appeared to be a really nice bloke but he’s meant to be an expert. He earns a living and buys expensive suits on the basis of his “expertise.” The question is… If he can get it as badly wrong as he has done, do I really think that he’s competent in his job? If I did as badly in my job as he’s done in his, I shudder to think what might have happened.

Anaesthetist 1 Surgeon 0

We're halfway through a gall bladder operation

Consultant surgeon to surgical SHO: What passes through the foramen spinosum?
Me: I know that one! It's the middle meningeal artery
Surgical SHO: Which is a branch of the maxillary artery
Me: I'm an anaesthetist and even I know that. I've got one for you guys
Surgical SHO: Go on...
Me: What's the equation for heat generated by the diathermy machine?
Surgical SHO: ...
Consultant surgeon: ...

One of the few advantages of exam revision is that occasionally, you get to look dead clever at work...

(p.s. if you're really interested, the answer is Heat is proportional to the square of the current divided by the area)

A night's sleep

It’s four in the morning and I’m working a night shift when my pager goes off. I pick up the phone and dial the number on the screen.

“Hello, staff nurse speaking.”
“Hello, it’s Michael here – anaesthetics – were you paging me”
“Yes, it’s staff nurse on the colorectal ward. Do you know Emma?”
“No, I’ve not met this person.”
“Well, she’s a patient on the ward who had a bowel resection yesterday evening. I’m calling you because we’re having trouble with her epidural. Over the last hour or so she’s been complaining of pain in her abdomen and it’s been getting worse. I tried to go up on the (epidural) rate, but she’s now saying that she’s in agony. I was wandering if you could come up and review her please.”
“Is her blood pressure OK?” I ask
“Yes,” comes the reply. “The last one was 115/70”
“And has this epidural been working at all since she got back from theatres?”
“It seemed to be earlier on, but, like I say in the last hour or two, she’s been complaining of more and more pain.”
“OK, I’ll come up and see her.”

I pick up my coffee (coffee is a god-send when you’re working through the night) and wander across to the surgical wards. I take a detour via the intensive care unit to pick up a vial of bupivicaine – just in case.

The staff nurse I spoke to greets me as I walk up to the nurse’s station and shows me where the patient is.

Emma is lying stock-still on her back and is grimacing. It’s four in the morning and this woman really should be sleeping. I ask her a few questions, check her observations and tell her my plan.

“What I think is best is that I give you a top-up injection down your epidural and that may well take the pain away. We’ll check your blood pressure a couple of times afterwards, but hopefully you’ll be much more comfortable. If it doesn’t work, then we’ll try something else. Sound like a plan?”

Emma nods at me and I inject 5ml of 0.25% bupivicaine down her epidural. I wander back to the nurse’s station and ask the nurse to check her BP in 15 minutes’ time. I sit down and chat to the nurse for a bit while scribbling something in her notes.

After 15 minutes I go back to see Emma.

“How are you feeling?” I ask. “Has it made any difference?”
She looks up at me and gives me a big smile. “Much better now thank-you. I don’t have any pain at all.”
“It’s gone completely?”
“Yes, thank you so much.”
The nurse checks her blood pressure which reads 121/75.
“Your blood pressure if fine, I’ll increase the rate that the epidural is running at. We’ll check your blood pressure again in about a quarter of an hour and after that, you’ll hopefully be able to get some sleep tonight”
“Thank you again, so much” Emma says to me and I wander back to ICU smiling to myself.

I think part of the appeal of anaesthesia is that just about everything you do makes a tangible difference to the patient. Whether that’s “big” things like an A&E trauma call, or “little” things like giving an epidural injection so a woman can get some sleep the night after her major surgery, you always feel you’re making a difference to help people.

(I think some credit should go to the staff nurse here too, stuff like this is much easier to sort out if the nurse is sensible and knows what she’s doing.)

Support

There can be no doubt that the job I do is really hard. By that I mean it’s really stressful and it can be really, really emotionally draining. I’ve seen lots of truly horrific things in the last few months and after trying my best to deal with each situation, I have to try and pick myself up again and try not to let it “get to me.” The emotional side is compounded, I think, by the very long hours that I have to work, the fact that I can’t choose to work near my family (thank-you MMC), that I’m having to spend all my spare time studying and the fact that there is a rather macho “just get on with it” attitude among doctors where nobody really talks about the horrible things on any sort of emotional level.

I’m really lucky though because I have a family who love me, a group of really good friends from uni who I know I can always call and a really lovely girlfriend to give me a hug when I need one.

A lot of doctors don’t have the support of a caring network of friends and family and I really see why some doctors struggle. It’s really easy to start to believe that you’re all alone, that every bad thing that happens is your fault and I can see why the rates of drug abuse, alcoholism, depression and suicide are disproportionately high among medics as compared to other professions.

I’m writing this because I made the journey to see my family at the weekend. I was chatting to my father about this and that and he stops and says to me; “You know Michael, I know it’s not often that I say this but me and your mother are really proud of you. Of the things you do and what you’ve achieved. We know you work really hard and you have a really tough job and I do pray for you.”

It’s amazing how just a few words can have such a big effect on me. I had a lump in my throat and just managed a quiet “Thank-you” to my dear father. But the point of this post is just to say that knowing that you have your family by your side no matter what makes shitty times like these MUCH easier to cope with.

Stages of Preparation

For the last few weeks, I’ve had my bum glued to the chair as I try and cram as many facts, principles and theories into my head as possible before my exam next month. I have to say that I feel much happier about my chances of actually getting through it now. I think that there are definitely certain stages that I go through when preparing for a big exam like this one.

Stage 1: Denial.

I think to myself that “everything is going to be OK, other doctors have passed this exam, so it’s obviously not impossible.” I have a vague notion that I’ll need to do “some work” at some point but I’m not at all concerned by the prospect

Stage 2: Trepidation

You can count the number of weeks to the exam in single figures now and I start to get tetchy. I look at some example questions and realise that I can’t do any of them. I look at the pile of anaesthetics books that I have and it hits home hard that there is a HELL OF A LOT of work to get through. At the same time, I’m almost scared to face up to it and start studying in earnest because I know how miserable studying is.

Stage 3: Fear

I’ve tried to learn stuff. I’ve been trying to remember the anatomy of the spinal cord or the shunt equation and its applications, but it just won’t go in. I just don’t “get” it and I can’t remember it all by rote. Everything that goes into my brain leaks out again and I feel I’m never going to know enough. It’s about this time when I start panic-buying more textbooks and ringing round revision courses to see if they have any last minute places.

Stage 4: Hope

Eventually, this stuff starts to stick. I begin to understand it. I realise that I actually DO know some stuff. I CAN derive the Bohr equation from first principle, I CAN talk sensibly about pharmacokinetics and the 3-compartment model, I DO know the side-effects of phenytoin, suxamethonium and a host of other drugs. There’s a glimmer of hope and I realise that, provided I’m lucky and get asked about the topics that I know well, I might just pass.

Stage 5: Determination through the dark days

At this point, I’m thoroughly fed up with it all. I’m sick of the sight of my books, my house is a mess with bits of paper with diagrams and graphs on thrown everywhere. I’m working 56 hours a week (8hrs a day, seven days a week) and then coming home and trying to do my studying on top of that. I have no social life and there’s nothing fun to look forward to. I think to myself “You know what, these are dark days and I’m REALLY miserable. There is NO FUCKING WAY that I’m going to put myself through all this again if I can possibly help it. I’m not going to leave it to luck, I’m going to work even harder to make sure I pass this bloody exam. Failure is not an option.”

Stage 6: Consolidation

The exam is only a few days away, I’ve done all the work I can, I know my stuff now and I feel quietly confident that I’m going to pass.

At the moment, I’m somewhere between stages 4 and 5 and I'm just hoping I can get to stage 6 before the exam itself. I’ve still got a lot to do, but I’m actually starting to believe that I WILL be able to at least cover all the topics before the exam.

While I was away…

The big story that I missed during my self-enforced break to study was the disgusting treatment of a surgeon in Scotland who was suspended from his job, not for any concerns about patient care, but because he called one of the architects of the MMC fiasco names.

This appalling abuse of power has been condemned by a host of bloggers, especially as it appears that the person behind his suspension is hardly whiter than white herself.

Said surgeon has since been re-instated to his job, but, like the Ferret says, the whole episode leaves rather a bitter taste.