Just a quick note...

...to say a huge thank you to the three men who helped push my car out of the hospital ice-rink car park this evening.

I truly am very, very grateful.

I'm dreaming of a white Christmas

I was in a bit of a grump yesterday (it was a long day). I feel much better now. There's nothing I can do about the weather, so what will be will be. The good thing about Britain in the snow is that everywhere looks really beautiful and magical. Even the Kebab shop round the corner looked pretty.

I feel much cheerier now so here's a few pictures of this winter and my favourite Christmas song. Sing along if you know the words (I'm not sure Shane does).

Happy Christmas to everyone!

I’m not dreaming of a white Christmas.

At the end October, all the junior anaesthetists in my hospital were given the on-call rota for November to February. The first thing we all looked at was who had to work Christmas and who had to work New Year’s Eve.

This year, I’m lucky enough not to be working Christmas Day and I’m really happy about that. Spending Christmas Day in hospital on-call must be one of the most miserable and depressing experiences known.

Christmas Eve, however is a normal working day in my hospital and I have the misfortune to be doing a theatre list that’s notorious for running over time. (Was I naïve in thinking that in this brave new world of “patient choice,” that patients would “choose” not to have their elective major surgery on Christmas Eve and would choose to have it in the new year instead. Apparently so). I envisage that I’ll leave work at about 7pm on Christmas Eve and my plan is to drive the couple of hundred or so miles to my parent’s home after work that day. With a bit of luck, I’ll get there just in time to hear the bells ring out for Christmas Day.

However, hearing about all the travel dramas because of the weather has me quite worried. I’m just praying that the icy freeze that’s currently enveloping the country has loosened its grip by then because otherwise there’s the distinct possibility I could be spending Christmas stuck at work or worse, stranded in some motorway service station.

My Christmas “holiday” is short lived though, I’ve got to brave the roads again on Sunday evening for my on-call shift on Monday and then it’s back to work for business as usual for the elective operations on Tuesday.

I’m not the only one who has to do this; Dr. Grumble is also rather miffed by the situation.

I know there’ll be people reading this who’ll be thinking “junior doctors these days don’t know they’re born. They only work 48hr weeks whereas when I was a lad we worked 128hr weeks etc… etc… etc…”

But, as Dr Grumble also points out, working in hospital over Christmas used to be fun. Believe me, it really no fun being on call for intensive care over the holiday period. I think this Christmas, I’ll be mostly knackered.

But at least I’m not working Christmas Day his year.

Two things that made me smile today

The sight of two of our recovery nurses - one Iranian, one Australian - laughing and dancing arm-in-arm outside as the snow came down.

The fact that Rage Against the Machine are Christmas number one. Power to the people!

Raising doctors, the "beta" version

I've just read this brilliant post by Dr Edwin Leap MD. It's the text of a lecture he gave to new doctors starting at his hospital in America. It's more about life in general than it is about medicine. It's long, but it's well worth the read so, give yourself ten minutes, make yourself a nice hot cup of tea, sit back and enjoy his words.

Raising doctors, the "beta" version

Who is a doctor?

Beep Beep… Beep Beep…

My mobile phone shrills and I casually reach over and pick it up to read the incoming text message.

You have an appointment with Dr Kavelidis at 16:00 on 17/12/09. Please allow time for parking.

I furrow my brow in confusion. I haven’t made an appointment with my G.P. in fact I haven’t needed to see him in over a year. Besides, I don’t have a clue who “Dr Kavelidis” is, perhaps he’s a new G.P. at the practice. But it still doesn’t make sense I’m sure the GPs at my surgery are busy enough without having to randomly text people on their practice lists to trawl for business. Was this some sort of new QOF thing? Seems unlikely, I’m a healthy young man. Maybe FashionGirl has the answer.

“Darling,” I say and she looks up at me from the magazine that she’s engrossed in. “Did you make me an appointment at the doctors? I’ve just had a text telling me I’ve got an appointment in a couple of days and I never made one.”

She shakes her head at me and says, “No, I didn’t. Let me see that.” She has a look at my phone and says, “It’s odd isn’t it? Especially as there’s no “from” number.”

None the wiser, I delete the message and continue watching the telly. Last time I went to the GP, I did get a reminder text beforehand, so I assumed there’s been a mix up and I’ve go the text by mistake.

Two hours later, it hits me. I do have an appointment on Thursday, but not with the doctor, with the dentist.

I go over to the fridge where I’ve stuck the appointment card and have a look at the names. Sure enough Dr. Kavelidis’ name is on the card, just below "Dr. Chang" and just above, ironically enough, “Dr Anderson.”

So, it does beg the question, “Are dentists ‘doctors?’” On this evidence, apparently they are. It just seems a bit odd to me. Dentistry is incredibly competitive to get into. Like medicine, you need straight As at A-level and then you have to spend five years studying at dental school before you’ve earned the right to call yourself a “dentist.” So why on earth, after all that, would you want to call yourself “doctor”?

It’s not just dentists that are “doctors.” Apparently, these days psychologists are “doctors,” chiropractors are “doctors”, and even nutritionists are “doctors.”

Slag me off if you want, but I spent five years at doctor school to earn the right to call myself “doctor” when I treat patients and I find it rather annoying (and inappropriate) that people with no medical qualifications get to call themselves “doctor” when treating patients.

I know there’s a feeling in the modern NHS that “anyone can do a doctor’s job,” but it’s simply not true. The way I see it, if you think you can be a real doctor, go to medical school and graduate. That way, you’ll see for yourself how “easy” it is.

Now, I totally agree that a PhD is hardly a walk in the park either, and neither is a dentistry degree and I can see that people who’ve worked hard for years at these should have a title to show their achievement.

The solution, I think is to use a system like the do in the USA whereby medical doctors have the suffix MD after their names. I know that MD means something different in the UK, but now dentists, nurses, psychologists, chiropractors and nutritionists are “doctors,” sooner or later, every man jack is going to be a “doctor” and the term will be meaningless.

Dr. Michael Anderson MD

I like the sound of that.

In which we save money for the NHS

I’m on a morning ward round in the Intensive Care Unit and we’re discussing a patient I’d admitted the day before. Mrs Patel is a lady in her sixties with really bad respiratory failure due to a particularly nasty pneumonia. The previous afternoon I thought that if we gave her non-invasive ventilation (NIV) and adequate intravenous fluids, she may just turn the corner and start to get better.

Unfortunately, I was wrong. She continued to deteriorate and quite soon after she arrives on the ICU, her oxygen levels were still dangerously low despite the NIV so in order to prevent her from dying then and there I had to put her into a medically-induced coma, intubate and put her on a ventilator.

So there I was the next day, recalling this story to the ICU consultant, SHO, ward sister and staff nurse. We look at her blood test results, ABGs, chest X-rays etc… and it’s apparent to all of us that whilst this lady will probably get better, it’s going to take a while and she will need to stay on the ventilator for at least a couple of days.

I turn to Richard, the SHO, and say “Could you change her sedation to midazolam & morphine.”

“Sure,” he says as he picks up the drug chart. He crosses off the propofol & alfentanil and writes up what I requested.

(Basically I’ve asked him to change the drugs that are keeping Mrs Patel in a coma. Propofol & alfentanil are shorter acting, but much more expensive. Because we were going to keep her in a coma for a few days, I changed to the longer-acting but much cheaper midazolam & morphine.)

After scrawling the new prescription (it’s so true what they say about doctor’s handwriting) Richard says, “It won’t make any difference, you know.”

I raise an eyebrow. “What do you mean?”

“I mean, it doesn’t matter how much money we save by doing stuff like this, they’re still going to cut our pay.”

“True enough,” I concede.

“Well, if the other lot get in, they’ll dock our pay even more!” pipes up Julie, the ICU ward sister

“Could we please save the politics for the coffee room,” comes the irritated voice of our consultant. “Now, could someone find the result of this woman’s most recent ECHO?”

Suitably chided, we get back on with the job in hand.

Casualty

I’m not working this weekend, so I’ve been sitting in front of the telly with a can of beer (Grolsch is my tipple of choice at the moment). Disappointingly, there was nothing I particularly wanted to see on the box. Come Dine With Me didn’t appeal, and I detest the X Factor so much that I won’t even entertain the thought of having it on anymore (I’m seriously considering buying Killing In The Name Of…).

I flicked over to the Beeb and was greeted by the Casualty* theme. I can’t listen to that tune without wanting to say “Will everyone stop getting shot!” in a really bad cockney accent. Previously, I’ve said that I was no fan of medical dramas, but for some reason, I thought I’d give it a go. Maybe it’s because I had nothing else in particular to do or maybe it’s because I’ve just spent a month watching seven series of Scrubs, but I thought I’d see if Casualty had gotten any better since the last time I watched it.

I think it’s definitely improved. I was quite pleasantly surprised and even moderately entertained. Back in the day, Casualty always used to be about “guess the really predictable disaster” and tonight’s episode remained true to those roots. I can sum it up with: Man unscrews valve on bus/fluid starts leaking out/bus goes downhill on narrow country lanes/brakes fail/bus goes over cliff. I don’t think it’ll Casualty will ever top the classic “man in field/combine harvester” episode, but it’s good to see the producers continue to try.

It’s also good to see that at long last, the show has recognised the existence of us junior doctors. I’ve spent more time than I care to remember trying to explain to people that “junior doctor” and “medical student” are not the same thing and then explaining what we junior docs actually do all day. I think having us on telly will help a little bit. The juniors on the show all seem to be very attractive, much more attractive than any group of doctors that I’ve ever worked with, if a bit on the numptyish side.

All in all though, it kept me amused for three quarters of an hour or so, so it’s definitely a big step up on the last time I watched a medical drama on the BBC. I might even consider watching it again next week.

If anyone reading this and thinks that I really need to get a life and get out more, I totally agree - Big Ed has just texted me and now I’m off out dancing…

* “Casualty” is such an old-fashioned name isn’t it? I’d be interested to know if it’s still called “Casualty” any hospital in the UK today (I must see photographic evidence) because, as far as I was aware, they all changed their name to “Accident & Emergency” years ago.

Interestingly, more changes are afoot because it’s been decided that “Accident & Emergency” is now not a good enough name, so it’s going to become the “Emergency Department.”

In about 10 years’ time they’ll probably all go back to being called “Casualty” again. Who makes these decisions? What a waste of time and effort.

Scrubs

Almost exactly a month ago, one of my colleagues lent me the DVD box-sets of Scrubs Series 1-7.

I remember when Scrubs first started. I was still in medical school and at the time, loads of my fellow medical students were raving about how good it was.

I never really got into it though, mainly because, as far as I can recall, it’s never been on terrestrial TV in the UK (correct me if I’m wrong). I watched the occasional episode at mate’s places but would never have said I was a fan of the show.

Until now.

I think the show is absolutely fantastic, and it’s made me laugh out loud more times than I can remember. For those who don’t know, the series basically follows three American doctors as they progress through their training from their intern year through to becoming attending physicians and beyond.

I’ve heard people say that it’s “really realistic.” I wouldn’t go so far as to say that the show bears much resemblance to every day hospital life, but it does have moments that I really recognise. Bricking it at your first cardiac arrest call, trying to make a relationship work despite the demands of the job, the frustration you feel at the patients who just won’t help themselves as well as those who you feel you’ve made a real difference to are all shown at various points.

I realise this is rapidly turning into an advert, so I’ll stop. Anyway, the DVD is calling, I’m half way through series 7 now, so I guess my normal blogging will resume shortly.

In which I ask for help

One of my old posts keeps getting Japanese spam from a different commentor every time.

Do any of you know how I can stop this happenning without resorting to banning all comments?

Thanks

Sleeping is Cheating

My time working in Intensive Care is drawing to an end. I’ve been working here for three months now and I have only one more shift to go. It’s been really hard work and at times really stressful and emotional, but I think I’ve got a lot out of my placement here. I’ve learned loads of stuff and I think that when it comes to procedures such as central lines, I’ve gone from being “competent” at them to being “good” at them. I think the best thing I've got out of this placement is that I have now answered the question of whether or not I want to be an Intensive Care Physician as a consultant.

As I sit here typing, I think of a weekend I spent with friends earlier in the summer. One of my best friends had his stag do up in Newcastle and we all went up there for a rather debaucherous couple of nights of drinking far too much and abusing the stag. We had several rules to observe on said weekend and one of them was “Sleeping Is Cheating.” This meant that nobody was allowed to sleep during daylight hours and anyone caught doing so was suitably punished.
The reason I’m telling you about this is not because I particularly want to share what a group of mates got up to in a Northern city but that tonight I face a similar situation.

I start work tonight at 8pm in one hospital in one city. I finish my shift at 9am tomorrow morning. However, tomorrow morning at 8am I am expected to start work in my new hospital in a totally different town and work through to 5pm there.

How can this be fair? I’m pretty good at some things but my talents don’t extend to being in two places at the same time. I called my new hospital and was told that I absolutely could NOT have the day off to sleep, and that I MUST come to work as they are all expecting me. They are VERY DISAPPOINTED that I won’t be there at 8am and I should MAKE EVERY EFFORT to get to the hospital as soon as I possibly can.

So, it looks like I won’t be sleeping for a while, but then again, sleeping is cheating isn’t it?

Fuck the BNP

I’m not usually political on this blog, but the appearance of the BNP’s Nick Griffen on Question Time and the subsequent domination of the media by this fascist’s agenda has me absolutely fuming.

I don’t pay my licence fee for fascists and their followers to come onto political shows on one of the UKs great institutions and spout their hate-filled racist drivel.

Let’s recap some of the BNP’s policies (words in italics are my own comments).

· The forced deportation of 2,000,000 people (or 1 in 30) from the UK. Let’s not forget these will be British passport holders or working here with valid visas. These people will be stripped of their assets including homes and cars on the basis of skin colour.
· Millions of other Brits “of foreign descent” will be “encouraged” to return to their “country of origin.” Exactly what form this “encouragement” will take, I can only shudder to think.

I could keep going with a whole list of thing that these evil fuckers want to do, but I won’t because this post will get too long and I think you get the point already.

And yet, we have so many people who think that the BNP should be given a voice. I had to walk out of the ICU coffee room on Friday because I was so mad with one of the consultants who thought it was right that the BNP should be on Question Time. Fellow bloggers such as The Jobbing Doctor think it’s OK for people to say stuff like “Islam is wicked,” and “There’s no such thing as a Black Englishman” on national television. People who defend the BNP’s right to hate speech seem to have no regard for the targets of the BNP’s vitriol. They have no regard for their fellow citizens, instead they prefer to stand behind the right of the racists even though the very things the racists are saying would deny rights to some of their fellow countrymen based on skin colour.

Why do people in the country find it so hard to say “No.”?

What happened to the British backbone? Why can’t we stand up to these evil people and say, “This is WRONG. You are WRONG. What you are saying is WRONG and we shall have no part of it.”?

This whole episode is deeply shaming on us as a nation and a lot of people need to take a good look at themselves and be honest about what their values really are.

Fuck the BNP.

Thinking about this is getting me angry again, so I’m going to leave you with the words of a Mr Richard Reynish whose letter was published in The Guardian on Friday.

"As Britain debates the BNP’s appearance on Question Time, it would be a good idea to learn from developments elsewhere, before it’s too late. Here in Denmark, where I have lived for 30 years, we have witnessed the systemic hijacking of a progressive and tolerant culture by the far right dressed in “respectable” sheep’s clothing. In 10 years, Denmark has been transformed into a country where racism is in the mainstream.

Free speech has protected hate speech, and opponents of censorship have consistently defended the rights of unscrupulous populists and incendiarists. When the media take this line, a very wicked circle is started: the inflammatory accusations of racists become self-fulfilling prophecies, as minorities are increasingly marginalised and excluded. Mainstream political parties, attempting to win back voters from the far right, make an endless series of concessions, attempting in vain to demonstrate understanding of the concerns of voters tempted by simple xenophobic policies. But the far right will always have a more extreme policy, and a new provocative proposal, which keeps them permanently centre stage in the media.

The “debate” about immigration – in reality a platform for populist racism – dominates politics, poisons serious dialogue an guarantees one thing: racist dominance of the media and the political agenda. "

Richard Reynish
Copenhagen, Denmark.

In which I embarrass myself

It was Friday and once again, our intensive care unit was overfull. We didn’t physically have enough space to accommodate all the people in the hospital who need to be on ventilators. The short-term solution for this common problem was to use the ventilators in the theatre recovery area and to nurse our patients there. This arrangement cannot last too long though as we don’t have enough nurses to properly look after the extra patients and the theatre recovery ventilators are needed for, well, for theatre recovery.

A more permanent solution is to discharge patients from the intensive care unit (ICU) to make space for the extra patients. If they are well enough, sometimes patients can go to the ward, but on Friday we really didn’t have anyone in that position. Our only option was to transfer one of our patients to another ICU in a different hospital where they did happen to have some space.
Obviously it’s unfair and unsafe for paramedics to transport these critically ill and unstable patients by themselves, so one what happens is that one of the intensive care doctors and one of the ICU nurses travel with these patients in the ambulance to look after them during the journey, and also to hand over the details of their care to the doctors and nurses in the receiving hospital.

And so it is that I find myself in the back of an ambulance taking one of our patients to another hospital.

Anyone who’s ever taken a ride in the back of an ambulance will tell you that the windows are obscured so you can’t see out. Usually I’m not susceptible to travel sickness, but this day was different. We had the heating up to stop our patient getting cold, the ambulance rocked rolled as we went round corners. I hadn’t been feeling well most of the day, I was tired from being on call the day before and hadn’t eaten very much because I had an upset belly.

It was the speed bumps that really did it for me. Andy, the nurse who was travelling with me said, “You’re being unusually quiet today, Michael.”

I looked at him, but couldn’t seem to focus properly. His features swam before my eyes and I knew then that I was going to spew.

“I feel horrific,” I mumbled. “I’m going to be sick”

He raised an eyebrow. “Really?”

I could only nod because my mouth was filling with saliva and I was holding my breath in an attempt to delay the inevitable long enough to grab a sick bowl.

“Here, take this” said Andy as he quickly pulled a cardboard sick bowl from the pile in which it was stacked.

I accepted it gratefully and promptly vomited into it.

“There he blows!” came the amused voice of the paramedic in the front seat as up came the remnant of my cornflakes and the cup of coffee that I’d had just before leaving. But it didn’t stop there, I spent the next quarter of an hour retching bile as the ambulance zoomed through the city with its blue lights on and the siren going. I hadn’t felt so miserable for ages.

I had never felt so grateful to see another hospital as I did when we pulled up outside the A&E of the receiving hospital and I was able to get out into the fresh air. Our patient was absolutely fine though and on the inter-hospital transfer paper work I wrote “Uneventful transfer” in the comments section and, of course, I made Andy promise not to breathe a word about this to anyone else in the ICU.

Credit

During a quiet moment yesterday, I was able to make my way down to the doctor’s mess and spend 20 minutes or so with a newspaper and a cup of tea. Flicking through the pages of the a Saturday magazine, I came across an interview with hip hop star Dizzee Rascal.

Who is the biggest hero of the
decade?
“Nurses, doctors and firefighters”

After what seems like years of negative stories about the NHS, it’s nice to hear us being given some credit for once.

Now I Know

I’ve not blogged much lately because my current job is really hardcore and I haven’t had that much time and I didn’t want to spend the free time I have had blogging because it reminds me of work.

In August, when I started working in Intensive Care the lead consultant, Dr. Cullen, asked me whether or not I wanted to do Intensive Care as a future career. At the time I really had no idea, and told him as much. You see, to us anaesthetists, Intensive Care work is a bit like Marmite in that it we either love it or hate it.

I worked in ICU in my first year of anaesthetic training, but at that time, I felt I didn’t really get a feeling of whether it would be something I’d like to pursue further down the line. I felt that I didn’t know enough stuff to be really useful and I didn’t know enough to actually make a real difference to the patients that I was helping to look after.

I’m now coming to the end of my current attachment in ICU and yesterday Dr. Cullen asked me again if I would consider intensive care as a career. This time I had an answer for him – no.

There are things that I really like about working here, I like it when we’re given a rapidly deteriorating patient, and I can stop their demise and (hopefully) put them on the road towards recovery. I actually like going round the wards and being able to be useful to other doctors who are struggling to look after their ill patients. I like the fact that I can actually do the majority of medical procedures, I’ve done dozens of central lines, arterial lines, intubations, chest drains, difficult venflons etc… etc… and these things no longer hold any mystery or worry for me. I like the fact that the ICU nurses are so switched-on and the fact that there are so many of them means that they can help us doctors out more which means I get to concentrate more on actually trying to get our patients better.

ICU is no land of milk and honey though. There are lots of things I really don’t like. A while ago, I wrote about why doctors get stressed and about some of the ways they cope. I said that simply being around unwell people is uncomfortable for people who have dedicated their lives to trying to make people well. I’m finding this really true of myself. Even when everyone is totally stable and there’s not much happening, I find just being on the intensive care unit stressful. The constant beeps, the almost continual alarms of the infusion pumps, monitors and ventilators, the fact that I know that things can, and often do, go tits up at any moment, all this things conspire to put my blood pressure up.

Our patients are all teetering on the brink of death. Actually, it’s more accurate to say that they’re well past the brink and with our machines we are desperately trying to push them back ONTO the brink so they have a fighting chance of living. This means that one of our patients will frequently drop their oxygen levels or blood pressure to a dangerously low level. They often hallucinate and try to pull out the very tubes that are stopping them dying. While the nurses are very good at sorting these things out, often they’ll need help just to stop the patient from expiring and it’s me that has to go and sort these problems out. Often I feel I’m fighting a pitched battle against the very people I’m meant to be helping. I find it frustrating that I can’t talk to my patients and that they’re often on the ICU for so long with only very tiny improvements to their health each day.

And then there’s the relatives. Seeing your husband/son/mother/grandpa/sister/friend unconscious and hooked up to all our machines must feel horrible. I can’t even imagine how I’d feel if I saw my mother lying their as one of our patients, I shudder at the thought. We try our best to explain what we are doing but I find having these conversations difficult simply because I don’t know what’s going to happen to their loved one. The two commonest questions a relative asks are “Is my loved one getting better?” and “Is my loved one going to die?” And the trouble is, often I simply don’t know if they’re going to live or die and, unlike when I was a physician, often I don’t even have a handle on how likely survival or death is. The uncertainty is often really hard for relatives to understand and deal with. But what I think is even more difficult is the timescale. As I already alluded to, patients stay unconscious with only very slight changes in their condition for days or weeks. We as doctors can see the subtle changes in their inotrope requirement, ventilatory demands etc… but basically, from the outside they look exactly the same. (Actually, as time passes, ICU patients look aesthetically worse as they swell up with fluid and accumulate puncture scars from all the tubes we keep sticking into them.) While we try to explain what’s happening, the seeming lack of progress after such long periods of time is often really distressing because relatives are sort of suspended in a seemingly unending, hellish limbo. Seeing relatives upset in turn upsets me because I too want their loved one to get better quickly, but it’s rarely possible and it leaves me wishing I could do more when I just can’t.

Dealing with other doctors can be wearing as well. There’s a constant trickle of calls for little things like venflons, lumbar punctures, central lines etc…from acopic ward doctors but that stuff doesn’t really bother me. I use my discretion. I help out if the request is reasonable and I’m free and able, if they’re just taking the piss and trying to get me to do their job for them, I have no qualms about telling them where to go. No, there are two things that really get me. Firstly, some doctors seem to have the belief that every unwell person should be looked after by the intensive care team. This really isn’t the case. Sick patients often don’t need Intensive Care, but they need the ward doctors to pay close attention to their condition and give appropriate treatments and sometimes, it’s hard to get ward doctors to understand this. Secondly, there are the group of patients who have been blatantly mismanaged on the wards and then I get a call to see them and am somehow expected to perform miracles. This frustrates me no end too.

And finally, there are the times where it really does all go wrong. There’s the fast bleeps, there’s the trauma calls and there’s the cardiac arrest calls. On average, I go to two or three of these every shift (my record is eleven). These are the situations where people are literally at (or through) death’s door. Sometimes, there’s not much for me to do at these calls, but sometimes there is. Often they’re just a horrible disaster and often the patient dies, sometimes in a more painful and disgusting way than you ever thought was possible.

So all in all, I’m working hard in Intensive Care, but I’d hate to do this forever. There’s too much drama, too much stress, too much politics, and too much frustration. If I had to do this forever, I think I’d end up worrying myself into an early grave, there are far easier ways of earning a living. I don’t think it’s any coincidence that two weeks ago, I found my first grey hair.

Not everyone is happy

Apparently the pigs are a bit miffed about being blamed for the current pandemic...

What is really important?

“Dr. Lin, can I have a word please?”

Dr. Lin our college tutor which means that she is the person in charge of looking after the training of the junior anaesthetists in my hospital. I’ve worked with her a couple of times and she appears a pleasant lady. I want to speak to her about something that I’ve had on my mind for a long time now, but have only recently made a proper decision on.

Dr. Lin regales me with an even look and replies, “Certainly Michael, do you want to come through to my office?”

I follow her through to her little room and she clears a stack of patients’ records off her workspace and asks me “What can I do for you?”

I’ve been over this moment many times in my head and I figured the best thing for me to do is to just come straight out and say what I want to.

“I’d like to leave the rotation.”

I state the words simply. This is one of the biggest professional decisions I’ve made in my career and, to me, it feels like I’ve lit the blue touch paper. But there’s no fanfare, no fireworks, just a slightly surprised look in Dr. Lin’s brown eyes. I fill the silence.

“You see, my other half, she works in fashion and, as you can imagine, there’s been lots of job losses in retail over the past year or so. Anyway, she’s had to leave her job here and none of the retail firms are recruiting at the moment. She’s actually managed to get herself another job – one that’s actually better than the one she left – but it’s not here, it’s in London. London’s where all the big retailers have their head offices. She’s searched for a job round here and there really isn’t anything that she wants to do. So, she’s taken the job in the capital. She’s moved there already and I’d like to follow her.”

Dr Lin breaths out slowly, during one of our days working together, I chatted to her about my girlfriend and what she does, so she sort of knew a bit about our situation already. She takes her glasses off, slowly rubs her nose and speaks.

“You know Michael, I understand where you’re coming from. I think from my point of view, it’ll be a real shame to see you leave here. The other consultants and the secretaries all say good things about you, but if you want to leave…” her voice tails off and she sits back in her chair and sighs.

“You probably aren’t aware of this but one of my good friends was diagnosed with cancer a few months ago and is now off work, probably for good. When something like that happens to someone you really know, it brings a lot of things home. It really makes you think about life and what’s really important. And I’ll tell you what’s important…” She’s more animated now, she sits forward in her chair and jabs her glasses in my direction.

“Health, happiness, love… these are things that are important. Turning up here at the hospital to work every day, that’s not important, not in the long term, but love is. So, like I say, I totally understand why you want to go and be with your girlfriend, you two have been together a while now haven’t you?”

I nod.

“So of course I’ll support you when you want to leave.”

“Thank you,” is all I can say.

“Have you told the deanery about it yet?”

“Yes,” I reply. “I’ve already asked them what I need to do to transfer my number and I’m going to fill in the application form this weekend.

“Good.”

“Could I put you down as one of my referees?”

“Yes, of course you can.”

“Thank you very much Dr. Lin” I say once more and stand up and head for the door. I’m half way out when Dr. Lin says

“Oh, Michael.” I turn to see her with a conspiratorial smile playing on her lips. “Do you think that she’s the one?”

I give her a broad grin in return and say, “We shall see…”

Lest we forget

“Respect your elders.” It’s a phrase that just about every living person would have heard at some point during their childhood. The sentiment being that those who are older than us have more experience in the ways of the world and that their advice and opinions have a deeper grounding than us and our peers. In many cultures, this is taken further. Stories of our ancestors and forefathers are passed down from generation to generation with the hope that the young will gain knowledge from those that have gone before.

It seems to me that the modern way in different. We don’t respect our fathers, we don’t respect their experiences, and we don’t respect their knowledge. We don’t overthrow them or castigate them. We simply forget them.

I can point to the Credit Crunch of 2007 and the ensuing worldwide recession as a prime example. It’s not as if recessions or market bubbles are a new phenomenon. It’s not as if the factors leading up to a recession are deeply buried secrets. All the documents, all the policies and legislation from the 1920s and even 1980s are all fully out in the open in the public domain. We could all have read all about it if we wanted to – but we didn’t. We didn’t know the history, we didn’t care about the history, we believed that “That was all yonks ago, things have changed now and that disaster couldn’t possibly happen in the modern era.”

We were wrong. It could happen again and it did happen again.

But that what we modern westerners do, we think often about the present and sometimes about the future, but never about the past. Our fathers have always been dead to us. We simply forget them.

It’s happening again. As you sit reading these words, we are in the midst of a global influenza pandemic. Again, 'flu pandemics are not a new thing. We’ve been through them before. Our fathers died in bygone pandemics and those who survived documented what happened so that future generations could learn. We know how pandemics behave and what’s great about 2009 is that we don’t have to go rummaging around old musty libraries to find out. The information is at our fingertips, merely microseconds away. It’s not even in the dim and distant past. There are thousands of people alive today who lived through the last pandemic.

The pandemic hits in the summertime with a large increase in the number of cases. Attempts to halt the spread of the disease fail for a multitude of reasons but at the height of summer, the number of people with the illness falls as people go off on holiday. When they and their children return in the autumn, the disease comes back with a vengeance killing more and more as autumn rolls into winter. Can you guess what’s happening with the swine flu pandemic now autumn is here and schools have resumed?

I guess that human flu has been around as long as humanity itself and in some ways it’s surprising that in this day and age we have remarkably few weapons at our disposal to fight it. Unlike their antibiotic cousins, anti-viral agents such as oseltamivir (Tamiflu) and zanamivir (Relenza) are actually pretty ineffective at treating the flu so, if we get the disease we pretty much have to rely on our own immune systems to fight the disease. History tells us that for a lot of us, our own immune system won’t be up to the task.

So what can we do about it?

As far as I can see, our medical and political leaders are doing what they can. Trust me, I’m no apologist for Liam Donaldson or Gordon Brown but they have at least tried to get the handwashing message out and the antivirals to the right people. More importantly, they have done the best they can to keep the worried well from swamping GP and hospital services. They’ve tried not to panic the population as a whole but, as I say there’s no decent treatment for flu and there’s not much we can actually do for people with flu apart from try and support them as best we can. It seems to me that our best hope of avoiding the deaths that we’ve seen in previous pandemics lies with a swine flu vaccine.

And yet… and yet…

Speaking to my colleagues, it seems that for a variety of reasons, many won’t be taking the vaccine. Polls among the profession show a similar story. We’ve had UK medical blogger Dr Crippen writing in the national press that the vaccination programme is a load of codswallop and that he certainly won’t be having it. There seems to be an ingrained resistance to this simple public health measure and it seems churlish for us doctors as a profession to expect other people to have the vaccine if we won’t have it ourselves.

Personally, I believe that when the first nurse or junior doctor dies from this disease, it will change the attitude of many of my peers, but it’s a shame that it will actually take the death of a colleague for people to start to pay attention to what the past has told us.

But, like I say, this is the modern way. We only think about the present and we forget the lessons that our fathers try to teach us.

Back to business

After having an amazing holiday in the Balearics with friends, I got back to business again last week. I have to say that my current ITU job is really hard work. I’m working lots of long days and, as you can imagine, I have lots of very sick people to look after. You know those pictures you sometimes see of patients in intensive care where they’re plugged into big machines, loads of pumps and have loads of tubes coming out of all parts of their bodies? Well basically, every single one of my patients looks like that. At first the knowledge that I had to look after these people and somehow try to get them better was really bloody scary for me. Now, nearly two months into my job, it’s still really bloody scary. It seems that ITU is the embodiment of Murphy’s Law in that whatever can go wrong will go wrong.

The thing is, I’m enjoying what I’m doing. I appreciate that I’m getting good experience in looking after the sort of patients that you just don’t get to look after outside a large teaching hospital. Currently, we have patients with head injuries, transplants, complicated haematological malignancies and even (whisper it) swine flu. Trying to keep patients alive when three, four or five of their organ systems have failed certainly taxes the brain. I’ve been spending much of my free time with my nose in textbooks trying to get my head around stuff like diabetes insipidus, alveolar recruitment strategies, chemotherapy regimes for acute promyelocytic leukaemia, oesophageal döppler studies and more about bacteria and fungi than I ever thought was relevant.

Practically speaking, I’m getting really good at the procedures that we do. On average, I put in one or two central or arterial lines each day and now I’m pretty confident of getting them into most people, no matter how fat or coagulopathic they may be. I’ve learned the hard way that intubating critically ill people and putting them on a ventilator is a whole different ball game to doing it to relatively well people before their surgery. I knew that already, but it’s one thing being told about what can happen and quite another seeing it happen in front of you and having to deal with the consequences. (n.b. that particular patient was OK and I’ll blog about it another time).

I’m still not sure whether or not I want critical care to be part of my future career. I’ve blogged before about doctors and stress and I have to say that I still find just physically being on the critical care unit surrounded by all those sick people a stressful experience. Even when they’re all relatively “stable,” bitter experience has taught me that they can (and frequently do) get very sick, very fast. This knowledge means that I’m constantly on edge whenever I’m working. Perhaps this feeling will go away as I get more experienced, but perhaps it won’t and I’ll end up worrying myself into an early grave. Who knows? Also, from what I see, there is an awful lot of politics involved in running an intensive care unit and I’m not sure I could be arsed with all of that.

All in all, I’m working really hard and I’m enjoying it at the moment, although I’m not sure I could keep doing this forever.

The NHS in the media

For a while now, there’s been something that’s been baffling me about NHS stories in the media. People I meet think that the NHS is awful and slag it off and it routinely gets a pasting in the media about how bad it is and about how low the standards of care are etc… etc… On the front page of today’s Telegraph, they were at it again.

'Cruel and neglectful' care of one million NHS patients exposed
One million NHS patients have been the victims of appalling care in hospitals across
Britain, according to a major report released today

However, this doesn’t tally with my experience from the “inside.” Just about every single day, my patients and their relatives thank me and tell me I’m doing a good job. I have a growing collection of thank-you letters from patients and their relatives. The vast majority of patients on the ward seem very happy and very grateful for the care that they are getting. This isn’t just my experience either.

The Care Quality Commission’s patient survey says that 93% of patients thought that their care was “good” or “excellent” and just 2% though it was poor. Put another way, a massive 98% or out patients were satisfied with their treatment. What other organisation, public or private, can boast 98% satisfaction from it’s customers? Your bank? Your electricity company? Your plumber? Your mechanic? Your restaurant? Your hairdresser?

When the Yellow Pages found that a mere 84% of its customers were satisfied, they used it to front a huge advertising campaign. When you put it into context and realise that hospitals do far more difficult and complex things than say a builder or and water company, you start to realise that the NHS is truly amazing. Admittedly, it’s not perfect. 2% is 2% too much and there are definitely improvements still to be made, but, looking at the big picture, it’s pretty damn good.

So why do the media keep running these stories that say the opposite? Why have The Patients Association come out with this “report” of theirs?

I’ve done a little investigating and it’s been very revealing indeed. A look at the list of The Patients Association’s backers proves very interesting.

BMI Healthcare. MediRest. Cardinal Health, The Harley Medical Group, Virgin Healthcare etc… etc… Basically, it's a list of private healthcare companies and pharmaceutical companies.

Now, I’m not saying that The Patients Association is merely a front for private healthcare companies. Nor am I saying that private healthcare companies are using The Patients Association as their mouthpiece to the media in order to slag off the NHS. All I’m saying is now I know where these anti-NHS stories are really coming from, and why the media do not reflect the experience of the overwhelming majority of our patients.

Finding my groove

After nearly two weeks at my new hospital, I’m starting to bed down a bit and find my groove now. I’m working as an intensive care registrar and, as you can probably imagine, the responsibility that my new job involves is huge. Out of hours, I am effectively the most senior person in charge of looking after the sickest people in the hospital, which effectively means that responsibility for the lives of the sickest people in the whole city rests on my shoulders.

On my first day, one of the consultants walked all the new doctors around the intensive care unit (ICU) in order to give us a bit of a flavour of the sort of patients we’ll have to look after. At first, I was just a bit overwhelmed by the sheer size of the ICU. There are about 40 or so critical care beds and the variety of illnesses that the patients have is also huge. There are the usual patients with sepsis, multi-organ failure etc, but there are also patients who are post-transplant surgery, and there are those with head injuries, conditions I’d never looked after before.

Starting a new job is always daunting, but I think I’ve settled into it surprisingly quickly. For the first few days, my main emotion was “Oh shit, I don’t know what to do,” but I’m getting over that. I’m realising that actually, the majority of the time, I do know what to do and on the occasions when I genuinely have no idea, there are always people around who can help me out.

As a result, I’m actually starting to enjoy working in intensive care. I admit that I was dubious about it at first, but I’m finding that I like dealing with sick people, I like making an intervention, starting a treatment and seeing people respond to it, and (hopefully) start to get better. It also gives me the feeling that I’m actually being really useful, that I’m able to help out and to make an immediate difference to the patients. I will confess that once the patients are stabilised on the ICU, I still find the slow progression of their treatment really frustrating, but like all jobs, you have to take the rough with the smooth.

All in all, while the step up from anaesthetic SHO to anaesthetic registrar is undoubtedly a huge one, I think I’m coping with the transition quite well. Maybe, just maybe I was ready for the step after all, despite my previous doubts.

Best of luck!

To all the doctors changing jobs tomorrow, to everyone starting work in a new place with new people, to the FY1s starting for the first time, I wish you all the very best of luck.

Stepping Up

Tomorrow, I start work as a registrar. A registrar in Anaesthetics and Intensive Care, to give me my new job title. I'm about to make the step up from the ranks of "the junior doctors" to "the middle grades"

I’m starting a new job, in a new hospital (in fact, at TheBigTeachingHospitalDownTheRoad) with a greatly increased level of responsibility. I’ve now completed the transition from being “the doctor who knows when to get help” to being “the help.” Previously, I’ve known that if I found myself in a situation that could get out of control; that I could call on the anaesthetic registrar to come and bail me out. Now, I’m the bail out person and there’ll be no one around to bail me out if things go wrong. That thought is pretty scary.

It feels like I’ve come a hell of a long way in what seems like a vanishingly short period of time. Two years ago, I gave my first simple anaesthetic to a patient. From tomorrow, I’m going to be expected to look after the intensive care unit out of hours. I’m going to be expected to know what to do with all the life-support machines that the patients are on. I’m going to be expected to manage all the various inotropic infusions, the ventilators, the haemofilters and dialysis machines. I’m going to be expected to know what to do with intra-cranial pressure bolts, jet oscillators and all manner of complicated things. To be honest with you, I’m a bit worried.

I’ve got a slightly empty feeling in the pit of my stomach, like I’m standing on the top of a very high building, leaning over the edge. I’ve had this feeling before, I recognise it well. I had it when my Dad was driving me down for my first day of university. I had it the first time I stepped into a hospital as a medical student. I certainly had it on my first day of work as a doctor. I had it the first time I was fast-bleeped to A&E resus as a medical SHO. I had it the first time I was on-call for anaesthetics, and tonight, I’ve got it again.

It’s partly the fear of the unknown, but it’s mostly the fear of what can go wrong. It’s the fear of hurting people, of doing the wrong thing, of not being able to help someone who needs my help.

Perhaps I’m being a bit dramatic, I don’t feel anywhere near as scared as I did on my first day as a doctor. I actually feel that things are going to be OK for me and for my patients. I know that the consultants and the nurses will know that I’m new and that they won’t be expecting miracles from me. I know that I need to ask about things that I don’t understand, and I have a feeling that I’ll be asking a hell of a lot of questions initially. Given a choice, I would have preferred to have another six months as an anaesthetic SHO, but our training is not set up that way and I’ve got to make the step up now.

So here I am, swotting up on the Surviving Sepsis Bundles and wondering how I’m going to cope tomorrow when I walk on to the intensive care unit as “the new reg.”

Work is about to get a hell of a lot more interesting…

The European Working Time Directive (again)

So, the European Working Time Directive has finally come into force for doctors in training, and it’s in the news again. Last year I wrote about what I felt about the EWTD and why I think, overall it’s probably a good thing. I haven't really changed my opinion in the intervening time.

Basically, if you’re organised and the system is on your side, there’s an awful lot that can be achieved in 48 hours.

Swine 'Flu

I've outlined some of my concerns about the H1N1 pandemic before on this blog. The people at the Daily Mash made me smile today and realise that my concerns are certainly not shared by all...

Emma Bradford, from London, said: "I have definitely got it because my Blackberry said so. I shall be collecting my Tamiflu from the chemist and then taking advantage of a last minute recuperation deal to Menorca."
Tom Logan, from Finsbury Park, said: "I would say I'm about 30% sure I'm not feeling well, but I'm 100% sure that I have just come up with a copper-bottomed reason to extend my summer holidays.

For whom the bell tolls

Over the last couple of weeks, I've been penning a short story. I think one day, I'd like to write a proper novel but I think that this is something that can wait until I'm a bit older. I thought I'd try writing a few short stories just to have a go at something a bit more substantial that a blog post. So here is my first attempt.

I must stress that this story is fiction and that I am not the main character in the story. I also must warn that this is not a cheery story at all. See what you think.

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For whom the bell tolls

- A junior doctor’s tale

I’m awoken from my sleep by that noise. The piercing klaxon of the cardiac-arrest pager shatters my peaceful slumber like a claw hammer meeting a precious china vase.

I gasp. I’m confused and disorientated as, for a second, my brain attempts to make sense of the unfamiliar surroundings in which I find myself. Instantly, a dozen questions rush into my head, each vying for supremacy in the limited space of my semi-conscious mind. Where am I? What time is it? What’s that noise? Why am I awake?

It only takes a second for me to regain my bearings. I’m on the sofa in the doctor’s mess at the hospital. An hour or so earlier, the anaesthetic registrar on call had taken pity on me and told me to go and try and get some sleep. Fat chance. I didn’t think I would be able to but, despite my reservations, unconsciousness had quickly enveloped me with its unknowing caress. I had gratefully welcomed its loving arms and drifted off into a long, deep, unsensing sleep - the sort of sleep that you only get when you’re truly exhausted. As a house officer, I used to joke that this was the sort of sleep that was only ever experienced by junior doctors and the dead.

But that was over now.

This screeching klaxon is a truly horrific way to be awoken from such peace. I’m aware of my heart hammering inside my ribcage and, as I sit up, I have to pause as a wave of nausea passes over me. I take a breath. I know what that sound means. Somewhere in this hospital, somebody has died. Right at this second, nurses on one of the wards are scrambling around, gathering pieces of equipment in a last, desperate attempt to revive him or her. The klaxon of the cardiac-arrest pager is the final tolling of the bell for this patient. Whoever it is has finally come face to face with their own mortality and, as their bell tolls, they stand before their destiny. Whether they stand before St Peter and the pearly gates to heaven or before Cerberus and the gates of Hades, only they shall know. Regardless of what destiny awaits them, it’s our job as members of the cardiac arrest team to try and rescue them from their final judgement, or at least delay it for a little while longer.

The klaxon finally relents and the tinny, dismembered voice of the switchboard operator comes through to my pager.

“…Cardiac Arrest, Beeches Ward… Cardiac Arrest, Beeches Ward…

Cardiac Arrest, Beeches Ward… Cardiac Arrest, Beeches Ward…”

I feel for my second shoe and shove my foot into it. My body feels heavy and lethargic and I stagger as I stand. I ignore the irritated grunts of the surgical registrar who was attempting to sleep on the other sofa and head towards the door, towards the rest of the hospital, towards Beeches Ward.

I stumble into the corridor outside the doctor’s mess and the brilliant fluorescent lights cause pain to my sleepy, darkness-adjusted eyes. I squint, then screw them closed and rub them and start to make my way down the corridor. The initial shock of waking up has now subsided and my body is starting to respond to what I’m urging it to do. I start to run. A gentle jog at first, but I slowly pick up the pace, rounding corners and sidestepping linen trolleys as I hurry towards where I am needed.

As I run through the bowels of the building, I become aware that I am not alone. Up a head of me, I can hear of one of my fellow team members running to the same place that I am. Each of his footfalls echoes down the clinical, deserted corridors of this hospital at night time and I can hear his rasping breath as he struggles to get to Beeches Ward as quickly as he can.

I arrive at my destination and pull open the doors to enter the ward. Inside, a surprisingly calm and serene scene greets me. The ward is illuminated only by a dim, yellow glow from the desk lamps at the nurses’ station towards the far end. The darkness feels oppressive, like it’s somehow clinging to me as I make my way through it. I walk further inside, catching my breath and pulling a pair of rubber gloves from their wall-mounted box as I go. I wonder if there’s been a false alarm. Perhaps, there’s been a mistake and there was no real reason for me to dash round the hospital at all. Maybe I’m still asleep and all this is a nightmare, the sort of twisted joke that my sub-conscience plays on me more and more often these days.

My hopes of a last-minute reprieve evaporate as I venture deeper into the ward. I hear the electronic triple-salute of the defibrillator and, as I approach, I can make out a female voice breathlessly counting out chest compressions.

“… 26… 27… 28… 29… 30… and breathe…. and breathe… 1… 2… 3… 4…”

I enter the four-bedded bay where this drama is playing itself out. The curtains are drawn around the bed of the patient in question, a soft pool of light spills onto the floor underneath them and I can make out silhouettes moving around the bed. The torso that the voice belongs to bobs up and down hypnotically in time with her counting.

“… 14… 15… 16… 17… 18…”

I glance to my left and catch the eye of one of the other patients in the bay, an elderly gentleman in a burgundy nightgown. He stares at me and in his eyes I see fear in its purest form.

I look away.

I step inside the curtain. I have a job to do.

The scene that greets me is a scene that I have seen several times before and my heart sinks as I comprehend the futility of the situation.

On the bed lies the body of a man. My initial glance tells me that this man is was in his eighties and had obviously been unwell for a long time. His small, withered body lies lifeless and unmoving in the middle of the vast sea of his ward bed. As I glance over his cachectic form, I can clearly make out each rib, each bone, each sinew. The low lamplight turns the hollows of his eyes into deep crevasses, adding further to his skeletal appearance. He is wearing nothing but incontinence pants and even these are too large for his puny frame. His little legs stick out in an almost comical fashion, like those of a new-born baby. As we enter this world, so we shall leave it.

A student nurse kneels next to him and towers above him. She has both hands planted in the middle of his emaciated chest and with an unremitting, metronomic rhythm, she pushes the weight of her upper body onto the dead man’s chest, crushing his lungs, his blood vessels and his heart together in a desperate attempt to prevent the last, solitary ember of life from extinguishing completely.

“… 22… 23… 24… 25… 26…”

I know that it’s already too late.

“… 27… 28… 29… 30… and breathe… and breathe… and 1… 2…”

Her voice is husky and breathless as she pants out her count. I briefly pause to regard her as I move towards the old man’s head, picking my way round the scattered detritus that accumulates during these events. Her face is flushed and shines with the perspiration caused by her exertions. As she bounces up and down, her ample figure undulates mesmerisingly and her long, auburn hair succeeds in its bid for freedom, escapes from her hair band and cascades down to obscure her young face. Her vigour and her youthful glow contrast starkly with the man that she is crushing beneath her hands - yin and yang; hope and despair; life and death.

I put on the latex gloves that I picked up on the way in. Typically, they’re too small and the right one splits as I push my clammy hand into it. Nevermind.

I take the oxygen mask from the ward sister and push it firmly onto the man’s face. I look down at him as I do so and his eyes stare back at me, unblinking, unknowing, unliving. He has vomited. It strikes me that this was the very last thing he did before he died, a final parting shot to life that left him in this state – “good bye cruel world,” indeed.

I reach round behind me and pick up the plastic suction tube. I shove it unceremoniously into his mouth, dislodging his false teeth as I do so. The suction tube thirstily slurps up the vile red-brown fluid that foams out of his mouth with every chest compression that the student nurse does. I satisfy myself that I’ve drained his mouth sufficiently and clamp the oxygen mask back on the man’s face. As I do so, I can feel his face through my torn glove. His course stubble bristles beneath my fingers. His skin is cold and waxy but the vomit that’s running down his cheek is still warm. This sensation provokes a visceral reaction within me. Revulsion slithers through me and I have to close my eyes and concentrate on stopping myself from retching.

“… 29… 30… and breathe…”

I snap back from my personal reverie and do what I came here to do. With my left hand, I tighten my grip on the old man’s face and with my right, I squeeze the bag that forces oxygen into his lungs.

“…and breathe…1… 2… 3… ”

As she recommences the chest compressions, more blood stained vomit pours out of his mouth. I sigh as I push my fingers onto his mouth and pull his false teeth out.

“Two minutes is up,” comes the voice of one of the other junior doctors.

“Okay, let’s have a rhythm check,” says the medical registrar, who is presiding over this whole sorry charade.

He squints at the monitor which is displaying chaotic wiggly lines. He frowns and then concludes, “It looks like VF. We need to shock. Charge to 150 please.”

The defibrillator whirrs into life as it charges itself and prepares to deliver the electrical pulse intended to restart the octogenarian’s heart.

“Everybody stand clear… Shocking now.”

The old man’s body convulses at the electricity surges through it. It’s back arches heavenward as if it’s performing one last, grotesque dance. A glance back at the defibrillator tells me that the wiggly lines on the monitor have smoothed out into one flat line - asystole. Just when you think that things can’t get any worse, they inevitably do.

“Let’s give him some adrenaline and continue CPR.” instructs the medical registrar and the student nurse tucks her hair behind her ear and resumes what she was doing before.

“1… 2… 3… 4…”

CRACK. A loud sickening snapping noise emanates from his chest and causes the student nurse to pause.

“5…?”

CRACK. It happens again. Under the pressure of her compressions, the old man’s ribs have snapped, like twigs carelessly trodden underfoot. His emaciated body is literally crumbling in front of us.

“Carry on.” Instructs the medical registrar sternly.

“6…? 7…?” Her voice is quieter now, she’s barely whispering. I’m sure she can feel bone crunching against bone beneath her fingers and she continues to press into the pensioner’s chest. I look up at her and see tears in her eyes. They drip down her nose and fall onto the dead man’s neck where they mix with his bloody vomit and form a river running onto the bed.

A friendly hand touches her shoulder and the ward sister gently says, “I’ll take over now, dear” and gestures for her to step aside.

“What are his pupils doing?” the medical registrar asks me.

I don’t need to look, but I do so anyway, just to be sure. His eyes are half open and I peel back the lids to regard the state of what lies beneath. All I see are hollow, empty globes, whatever life was once there has definitely departed. “Pupils are fixed and dilated.” I tell him.

“Could be the atropine,” says the medical registrar, more in hope that expectation. We both know the reasons are more profound than temporary blockade of his parasympathetic nervous system. We both know that to carry on would be futile.

“I doubt it,” I say. “I think that this man’s ship has sailed. Even if we get him back, he won’t be coming to the intensive care unit. I think that carrying on is pointless.”

I look around. The house officer is studiously staring at his watch, timing things and trying his hardest not to look at the corpse in front of us. The student nurse still has tears streaming down her face and is being comforted by one of the staff nurses. Bless her, she’s probably never seen anything like this before. She probably gave him his last supper earlier in the evening. She probably still thinks that most people get better and those who don’t die peacefully. If continues working in the hospital, she’ll soon have such idealistic notions stripped out of her psyche. She’ll soon learn.

The medical registrar looks at me and holds my gaze for a couple of moments. He sighs. “You’re right, I guess. Does anybody disagree?”

There are no dissenters.

“Okay, let’s stop.”

My hands fall to my sides and the whole team looks at one another.

“Thank you everybody,” says the medical registrar. “We tried our best.”

His words are of no comfort to the student nurse who can no longer contain her crying. She is lead away towards the coffee room by the ward sister. Her sobs grow quieter as they leave and I pause for a moment to look at the old man in front of me.

Is this how it ends for all of us? I wonder. Is this how we die? Covered in our own vomit with our body broken by a stranger’s hands? Whatever happened to dying with dignity?

That last thought causes a wry smile to play on my lips. “Dying with dignity,” There’s a quaint notion. There is no dignity in death, only pain and suffering right up to our last breath and, as tonight proves, sometimes the pain and suffering continues even after we have died.

I peel off the torn latex gloves and wash my hands. I wash my hands again, and again, and again, in a perverse homage to Lady MacBeth, as if by cleansing them, I can scrub the memory of the last ten minutes from my soul.

I turn to leave, and as I do so, my eyes meet those of the gentleman in the burgundy nightgown. It’s like he’s looking all the way through me. Perhaps he and the dead man had become friends during their stay in Beeches Ward. There is an almost pleading look in his eyes, as if he’s hoping against hope that we were his pal’s salvation. I feel an irrational pang of irritation as I look back at him. There is no salvation here. I give a short, curt shake of the head and see him slump back down into his bed in response. I wonder if I should offer some words of condolence, but I quickly think better of it. I have no words to say. The bloody vomit that still stains my shirt says everything that needs to be said. I straighten up and walk away.

The student nurses muffled sobs play on my ears as I leave Beeches Ward and walk back into the impersonal, fluorescent-lit corridor.

I enter the warm darkness of the doctor’s mess and retake my position on the sofa. The surgical registrar stirs as I disturb him from his slumber.

“Did they make it?” he asks me.

I snort in response. “Of course not. Don’t be silly.”

As I lie down, I can feel the adrenaline slowly leaching from my body. The energy is ebbing away like ripples on a lake and it leaves me feeling tired, so tired. I feel sleep start to envelop me again. As I descend once more toward that tranquil oblivion, a thought occurs to me: I never even knew the old man’s name.