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.

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.

Dear Nurse

Dear Nurse,

We are not going to take this old man to the CT scanner. You asked me why and I told you the reasons. He is a 91-year-old nursing home resident. He has a GCS of 3, his right pupil is fixed an dilated, his blood pressure is 212/95 and he has a heart rate of 54 bpm. The paramedics say that he had a dense left hemiparesis when they arrived and now he is unconscious.
I can see that you have a smart navy blue uniform and your badge says that you are the "Acute Stroke Lead Co-ordinator" or something, you are obviously a very important person. You can threaten us with clinical incident forms all you like, but I totally agree with the med reg on this one, going to the scanner would be a pointless waste of time, money and effort. There's no need to quote the NICE guidelines at me, I know what they say, but sometimes you have to ignore the guidelines.
Unfortunately, this man is going to die - CT or no CT - and what we should be doing right now is trying to make his last few hours as comfortable as possible. He needs care and to be allowed to pass away with dignity. He does not need a CT scan.

regards,

Dr M. Anderson

What a way to start the week!

So, I arrive at work today feeling all refreshed and keen after the long weekend. It’s just after 08:00 and I walk onto the intensive care unit, where I’ve been rostered to spend the day. The consultant, Dr Amduno, is already on the unit and as I walk on, he says, “Michael, could you go down to the medical and give Nathan a hand with a patient down there? I’m sure he’ll fill you in with all the details.”

“Sure,” I reply and do a U-turn and head towards the medical unit

Nathan is another anaesthetic SHO and he’s been working all night. When I find him, he’s with one of the registrars, fiddling with the portable ventilator. Nathan tells me that he got fast-bleeped to see this man who was fitting. The usual treatment hasn’t worked, so he intubated the patient and was in the process of preparing him for a transfer to the radiology department for a brain scan.

Nathan has got the man’s physiological parameters under control, so there wasn’t a great deal for me to do. I made myself useful by helping roll the patient so we could sort out his knotted hospital gown.

Nathan looks after the patient’s head and I grab the man’s hips. With the help of a couple of nurses, we roll him onto his side. As we hold him in that position while another nurse sorts out his gown, I feel something warm and wet against my leg.

I’ve got a bad feeling about this, I say to myself. When we roll him back and I let go of his sheets, I see that there is indeed a large damp patch on my right thigh. I touch the patient’s sheets again. They’re soaked. Oh no. I pull a face and look at the nurse.

“That’s not saline is it?”

She looks at me sorrowfully, shakes her head and replies, “I don’t think so.”

I look at the clock. It’s 08:14. I’m less that a quarter of an hour into the working week and I’m standing in clothes that are damp from a stranger’s piss. Whoever said that being a doctor is lamorous work is definitely lying. I wonder why they never show things like this on telly…

Blood on the dancefloor, part 2

This is a continuation of this post.

A bougie is basically a bendy stick, and when using one to incubate a person, you’re aiming to feel the stick running across the rings of cartilage in the patient’s windpipe – a bit like a child running a stick along a wooden fence. As I pushed the bougie down into this man’s body, I didn’t feel that sensation at all.

“Are you in?” asks Dawn, the ODP, who is standing next to my right shoulder, with the endotracheal tube (breathing tube) poised in her hand.

I don’t know if I’m ‘in’ or not. The bougie could be in this man’s windpipe, but equally, it could be in his foodpipe and, if I put the endotracheal tube into his foodpipe, he’ll quickly run out of oxygen and die. As this thought flashes through my brain, a surge of panic rises through my body. It feels akin to being suddenly woken from a deep sleep. My heart hammers against my ribcage and I actually start to feel faint. I need to focus. I clench my jaw and swallow and concentrate on what I need to do. I decided to do this to this man, so it's up to me to see it through to completion. I claim victory in my personal battle with my own emotions, a battle that lasted only a split second, and I look again into this man's mouth.

When I was putting the bougie in, my hands must have shifted slightly. Either that or the swelling and bleeding has got worse, because as I try to look down the man’s throat, I can no longer see what I thought I could see initially. It just looks like a bloody mess and I wonder if I ever really saw anything in the first place or if it was just my brain playing tricks on me and making me see what I wanted to see.

I figure that taking the bougie out and trying again is probably not be the best thing to do, but I did remember something that Dr Harrison told me when I was first learning how to use a bougie. ‘The trachea isn’t very long, even in the tallest of men. If you keep pushing the bougie down the trachea, you’ll get to a point when you can push it no further. If you push I down the oesophagus, you can pretty much push it all the way in.’

I push the bougie in further, and further, and further and it stops. I can push it no more.

“Oh, you’re definitely in!” says Dawn, who’s been intently watching what I’ve been doing. She puts the tip of the bougie through the endotracheal tube and I take hold of it and push into the man’s lungs. A few squeezes of the air bag and I confirm that I’ve put the tube into the right place.

"Well done!” says the surgeon and I breathe a large sigh of relief as Dawn tied the tube in place and Ken and I set about putting the man’s hard collar back on.

One of the things that I’ve noticed when dealing with acutely critically ill people like this is that as soon as the patient is intubated, everyone calms down a couple of notches. It’s almost as if the team breathes a collective sigh of relief. I think this mainly because when you induce anaesthesia and paralyse the patient, obviously they stop screaming and thrashing around which means that it suddenly becomes much easier for everyone else to do what the have to do. That could be that cutting off clothing, listening to the chest, feeling a pulse, palpating the abdomen, phoning radiology or simply taking in information and thinking about what the next steps should be. Whatever it is, it’s easier to do when you don’t have a screaming, thrashing patient in front of you.

I certainly noticed it with this man. I set the mechanical ventilator and sorted out sedation while the A&E consultant (trauma team leader) reassessed and went through her A-B-Cs again. When I suction down the endotracheal tube I get moderate amounts of blood back, and this confirms that my decision to intubate him was the right thing to do.

The patient (turns out that his name is Carl) was actually quite stable from the point of view of his vital organs. From a doctor’s point of view, one of the things that I quite like about dealing with trauma is that the management is relatively straightforward. What makes it difficult tends to be more the organisational and people-management side of things. With Carl, we were doing well. We quickly organised chest and pelvic X-rays and, whilst he was having these taken, I turned back to the paramedics and ask her again what happened to him.

“Basically, he was in a bar and from what we can gather was allegedly assaulted by two or three other men. Apparently they were kicking him and stamping on his head and it took security and the police a long time to get them off him. When we got there, he was pretty much as he was when we arrived here. GCS at the seen was 15, but he was combative and the only sats reading we got was in the 80s.”

Ugh, I think to myself. The bar in question does have a certain reputation for being really rough, but I’d never heard of anything this bad happening there. “Well, he’s certainly had a good going over,” I comment.

“It’s OK to come back in.” The voice is that of the radiographer, letting us know that she’d finished taking her X rays.

The paramedic stops me as I start to walk back towards Carl’s trolley “Can I just ask you something?” He looks rather tense, like there’s something playing on his mind.

“Sure”

“Well, when we tried to get a sats reading, it said they were 85%. I was thinking about putting in a NPA (naso-pharyngeal airway), but didn’t because of the state of his face…”

I frown and scrunch up my face, “I wouldn’t have…”

“No?”

“No.” I gesture towards the motionless Carl, “He could have fractures to his face… to his skull… we don’t know. A nasal airway could have made things worse.” A slight smile starts to play on his lips, “You did the right thing,” I conclude.

“Thanks.”

Carl needs a CT scan of his head to see if he’s bleeding into his brain and thus needs urgent neurosurgery. Someone gets on the phone to the radiologist and the radiographers go off to warm up the CT scanner.

Major trauma really is time-critical. The sooner patient receives treatment, the better their outcome is. If you have an interest in trauma, phrases like “the golden hour” and “the platinum 10 minutes” will be familiar. In situations like this, the clock really is ticking and every minute unnecessarily wasted is potentially detrimental to the patient. The thing is, it’s so easy to waste time. It’s really tempting to “stay and play” in the resus room. You can put in arterial lines and central lines, set up infusers, warmers, splints etc… etc… All of these things take time, but these things may not be necessary or even helpful to the particular patient in front of you. You can spend lots of time trying to “do every thing by the book,” but lose sight of the fact that the whole point of “the book” is to identify the patient’s injuries and get them treated as quickly as is humanly possible.

Anyway, I’m digressing a little. I’ve learned that one of the key things you can do to avoid time wasting is to think several steps ahead, and I’m getting better at this. Whilst waiting for the scanner to come online, I busy myself with setting up the pumps and refreshing the infusions and that are going to keep him asleep while we move him. I recheck Carl’s vital signs, give him some intravenous fluids and then go off and check I have all the equipment I’ll need on the transfer.

I’m going to stop now and not say any more about Carl and what injuries he had. The events I’ve described actually happened quite a while ago, but this ended up being quite big news locally and I don’t really want to say much more for worry of compromising Carl’s real identity.

All I will say is that Carl had surgery and survived to walk out of hospital several days later. Though Carl will never have any idea about what the paramedics and hospital staff did for him that evening, it does give me a real sense of satisfaction to know that as I sit here typing this, he’s out there somewhere living the life that I helped to save.

Blood on the dancefloor

The last patient on the emergency NCEPOD list is sitting in recovery after his operation. He’s drowsy, but comfortable and I’m chatting to Sara, one of the nurses when my pager goes off.

“Trauma call – A&E resus immediately please… Trauma call – A&E resus immediately please… Trauma call – A&E resus immediately please…”

I sigh and roll my eyes at Sara. “Just when you think all the work has been done, something else happens,” I say.

She smiles sympathetically as I turn and make my way out of Main Theatres towards A&E. To be honest, I’d been expecting this. I hadn’t had any trauma calls on my last couple of on-call shifts so, on the balance of averages, I was due one today.

Dealing with major trauma is one of the things that really worries me as a junior anaesthetist. Over the past few months, I’ve been making a big effort to improve my trauma management and get more experience of managing patients with major trauma. One of the things I wanted to achieve by the end of my ST2 year in anaesthetics was to be much more comfortable in situations just like this, and to some extent, I’ve succeeded. If I’d been in this situation a year ago, I’d be absolutely shitting it, but as I round the corner into the A&E resus room, I feel in control of my own emotions.

The first people I see are a couple of police officers looking intently at the scene that was unfolding in front of them. I give them a brief nod and headed into the resus bay.

The scene that greets me is bad. Very bad.

A young man lies on the casualty trolley screaming unintelligibly. He’s trying to trash around and two paramedics are trying their best to prevent him from hurling himself onto the ground. The bloody footprints of the hospital staff have created a perverse mosaic on the floor of the resus room as they desperately try and get control of the situation. A nurse has the man’s left arm locked in his vice-like grip in an attempt to keep it still as the surgeon is trying to shove a cannula into the man’s vein. I glance at the portable obs machine next to the trolley. It’s impassive display reads:

HR: -?-
BP: -?-
O2 Sats: 84%

Like I say, this is very bad.

Ken, the A&E charge nurse is trying to give this man some oxygen, but he screams again and thrashes his head from side to side.

“Are you the anaesthetist?” Ken, asks me.

“Yes, I am” I reply as I scan the bay for a pair of gloves to put on. The only box of gloves I can see contain small gloves, this has been a recurring annoyance throughout my medical career so far. I squeeze my goal-keeper hands into the gloves, quickly connect together an anaesthetic breathing circuit and turn on the oxygen. Ken stands aside as I plant my oxygen mask onto the patients face.

The patient looks horrific. His face is massively swollen to the extent that he cannot open his eyes and I cannot open them for him. The whole of his head is completely covered in blood, he is bleeding from his scalp, his cheek, his nose and appears to be bleeding from somewhere inside his mouth. My fingers keep slipping off his face as I try to hold the mask on to enable him to breath the vital oxygen.

Paradoxically, in the few moments that I’ve been there, I’ve been reassured by the situation. It’s probably not as bad as it looks. The mere fact that he is able to scream and fight means that he is not at the end of the road yet so, while things are undoubtedly very bad, they’re not yet critical. The surgeon has secured IV access and has moved on to examine the man’s torso.

“Can I have some suction?” I say and Ken passes me the Yankeur sucker which I put into this poor guys’ mouth. I suck blood, clots and saliva away from the back of his throat, which enables him to scream even louder.

"What's happened to this guy?" I ask. One of the paramedics starts to tell me the story, but to be honest I'm not taking it in at all. The patient is trying to sit up again and I lose my grip of my oxygen mask, which tumbles onto the floor.

“AAAAAAAARRRRRRGGGGGGGGGHHHHH!!!!!!!” he screams, but I notice that his scream gurgles towards the end as blood re-accumulates in his throat.

“This is fucked,” I state. “He’s got loads of blood in his mouth, he’s not spitting, he’s not swallowing, he’s probably going to aspirate if we leave him like this for much longer – I’m going to intubate this guy.” No one disagrees with me, and I quickly try to formulate a plan of how I’m going to intubate this man without killing him.

“Ken, are you OK to hold the oxygen mask while I draw up some drugs?” He nods to the affirmative and I hand him the mask, peel of my blood-soaked gloves and go to the drugs cupboard. It’s locked.

“Anyone got the drug keys?” I say, but I’m ignored as the patient continues to trash around. “WHO HAS GOT THE DRUG KEYS?” I shout. Sometimes, you have to make yourself heard.

“They’re over here,” comes the voice of Mary, one of the nurses.

“Thank-you” I say as she opens up the cupboard for me. I take out the thiopental and suxamethonium and start to draw the drugs into syringes. This takes a few moments and gives me time to pause for thought. I figure that this situation has the potential to go from serious to critical to fatal very quickly. Taking this into account, I conclude that it’s worth getting as much help as I can muster. I’m going to need to phone a friend.

“Mary, could you please call theatres and ask for one of the ODPs to come down to resus.”

“Certainly,” she says as she heads towards the phone.

“Oh, and Mary, could you also please bleep the ITU reg (my immediate senior) and ask him to come down too.”

I turn my attention back to the patient.

“Thanks Ken,” I say as I take the oxygen mask from him.

I put the Yankeur sucker back into the patients mouth and hoover out more blood. As I do so, he coughs and sends a spray of blood and saliva into my face. I feel the warm fluid trickle down the side of my face and my stomach turns. I make a face at Ken and he gives me a sympathetic look. “At least I had my mouth shut,” I say. Thank God for small mercies.

“Right, everyone; this man needs to go to sleep.” I say loudly. “Ken, can we take his hard collar off, now? And what I’d like is for you to do manual in-line stabilisation [of his neck], when the ODP arrives, she can do cricoid pressure and help me with the intubating equipment and we’ll get some one else to give the drugs.”

“Sure,” comes Ken’s response and he manoeuvres himself so he can comfortably keep the man’s neck as still as possible while Mary and I take off the hard collar.

I put the oxygen mask back on his face and right at that moment, like a cavalry unit, both the ODP and ITU reg arrive.

“I’m going to intubate him,” I tell them.

“What’s his GCS?” asks Ben, the ITU reg.

“Twelve” comes the voice of some bright spark in the bay. I’m pretty sure that his GCS is much less than twelve, but now is not the time to start a debate about it.

I shake my head, “He’s got a mouthful of blood and he’s not spitting or swallowing.”

“Can he maintain his own airway?” asks Ben

“No,” I reply

“OK then, I’ll draw some drugs up.”

“I’ve already got them,” I say. “They’re behind me.”

Ben picks up the drugs and goes round to where the surgeon had secured an intravenous cannula.

“Is everyone ready?” Ben asks. We all affirm we are. “OK, I’m giving the drugs now… Thio is in” the man on the trolley stops trying to fight us and becomes suddenly very limp. “Sux is in” The patient’s muscles ripple under his skin in an uncoordinated dance as the drug works its way round his body and paralyses every muscle as it goes.

I know it’s down to me now. Thanks to us, this man can no longer breathe and I have a small window of time to get a breathing tube into his lungs before he starts to die. The room has gone eerily quiet and I know that all eyes are on me as I pick up the laryngoscope and put it into his mouth. I’m hoping to see his vocal chords. What I’m aiming to do is push the tube between the chords into his lungs. They say that intubation should be a calm, smooth process, but I can immediately tell that this is going to be difficult.

All I can see is a lake of bright red blood. I pick up the Yankeur sucker and try to suck it away. The lake recedes annoyingly slowly, revealing the anatomical structures beneath it. But this doesn’t look like it does in the textbooks. It doesn’t look like any other intubation I’ve seen before. Everything is swollen, everything is red and everything looks sort of… twisted. I can’t see the vocal chords. I can’t see where I’m meant to put the tube. Worse, I can’t see any of the things around the vocal chords that are meant to give you a clue as to where to aim. I can’t see the epiglottis, I can’t see the arytenoids.

“Fucking hell,” I whisper to myself.

“Sats are 92%” comes Mary’s voice.

This man is starting to run out of oxygen and I’m going to have to do something. I pull harder on the laryngoscope handle, hoping to improve my view. The man’s throat is starting to fill with blood again, but I can’t see from where. Just at the limits of my view, I can see something pale and bumpy. I think it’s one of the arytenoids, but I’m not sure. I have a decision to make now. Do I step aside and let Ben see if he can intubate this man or do I try and do it myself, knowing that if I fail, it will be even harder for Ben to succeed? I trust my judgement and pick up the bougie [an intubating aid].

“What do you see?” says Ben

“Tricky,” I reply

“Sats are 88%” comes Mary’s voice again

Things are really serious now, I know that I only have a few seconds left to get the tube down before his body runs out of oxygen. There probably won’t be enough time for a second attempt before he is genuinely hypoxic. I hear the surgeon say something about a tracheostomy kit and have to act.

I push the bougie down where I think it should go and hope for the best.

To be continued…

When it all goes wrong

Some of the people that I work with have told me that I worry too much about things. Before anaesthetising a patient I check, check and check again. I do things that most deem unnecessary, and it’s been commented on a few times. I usually laugh it off and say that my paranoia keeps me sane. Sometimes it causes friction with my colleagues – I remember practically having a shouting match with the A&E charge nurse because one night I insisted on giving a general anaesthetic for emergency cardioversion in A&E resus rather than taking the patient to the Coronary Care Unit. I’m sure that as I become more experienced, I’ll “loosen the reigns” a little, but I think that I’ll always bring a healthy dose of paranoia with me to work.

The reason for this is that in anaesthetics, when things go wrong, they go BADLY wrong and they go badly wrong very quickly indeed. Yesterday, I was shown something that really crystallises this message.

“A mother who spent years undergoing IVF treatment died after a bungled birthand never saw the baby she longed for, an inquest was told yesterday.

Joanne Lockham had a Caesarean operation to deliver baby Finn but her brain was starved of oxygen for up to 30 minutes, it was claimed.

Within moments of the birth she suffered a heart attack and she died two days later after sustaining massive irreversible brain damage."

Reading a bit further into this story we learn that basically, the decision was made to give Mrs Lockham a general anaesthetic for her ceasarian section, after giving her the anaesthetic, the anaesthetist couldn’t put the breathing tube in the right place (couldn’t intubate) despite several attempts. By the time help arrived, she was already dead.

“…problems arose in the operating theatre. The jury heard that three attempts were made by anaesthetist Dr Prasad to insert a tube to give Mrs Lockham oxygen before it was eventually believed to have been successful.

Dr Prasad broke down in the witness box as he told how he repeatedly tried to intubate Mrs Lockham.”

It sounds like several things went wrong here but I’m not going to comment too much about the ins and outs of this case because I wasn’t there and don’t know all the facts, but I will say this. In situations like this, when things start to go a bit wrong, people start to panic. This is ESPECIALLY true on the labour ward. The midwives panic, the obstetricians panic, the scrub nurses panic and everyone starts telling you, as the anaesthetist to hurry up and get the patient to sleep. It’s noisy, the atmosphere is fraught and if the anaesthetist starts to panic, then things become INCREDIBLY dangerous. It sounds like Dr Prasad panicked.

“Dr Prasad said: 'I was doing my job, but I was in a complete state of shock, I couldn't think, I was trying to be useful in anything I could.

'I went in at that point in time with a particular plan and it didn't happen.

'It was completely out of the blue and the equipment was not giving way, so I didn't
know what to do, it completely numbed me, it was not what I was expecting.'"

This is a horrible situation for everyone and highlights the point that I’ve been told several times during my training – always be clear what your exit stratey is. The books say that Dr Prasad should have prevented the obstetricians from starting the caesarian section, woken Mrs Lockham up and waited for senior help to arrive. However, I can see that this is difficult to do when you have the consultant obstetrician and a room full of midwives yelling at you to hurry up and get the mother to sleep because “they need to get the baby out.”

This brings me back to my original point. I’ve not yet been in a situation like the one above by myself, but sooner or later, it’s goint to happen. Things are going to go wrong unexpectedly with one of my patients. At least if I’ve checked everything and know where everything is, when the panic starts to creep up on me, it reduces the amount of “thinking” I have to do and hopefully gives me more of a chance of sorting the situation out long before it gets to the stage that Mrs Lockham go to.

What happened to Mrs Lockham is truly tragic. Dr Prasad would have had to explain to her husband why he now has to bury his wife. What should have been a joyous occasion has become a horribly tragic one. Everybody involved will have to live with what happened for the rest of their lives. A child will grow up never knowing his mother.

My condolenses to Joanne Lockham’s family.

For more on this story, read here and here.

Made his own bed to lie in

I was just browsing some of the things I've written when I found this post from last year...

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I answer my pager and listen to what Tal, the orthopaedic surgeon, says to me down the phone. I sit on the intensive care unit (ICU) and my heart sinks a little as he explains the story. It’s 3 a.m. on my third night on the trot and, to be honest, I’d been semi-expecting a call like this at some point. I sigh and tell the surgeon that I’ll be down to A&E soon. As I leave ICU, I scoop up some drugs and let the ward sister know where I’m heading. She rolls her eyes as I tell her what’s going on. “I know.” I respond, “I just don’t understand what some people do for kicks.”

I take a stroll down to A&E through the empty corridors of the hospital. My clogs create a faint echo with every step I take. I have a few moments to think about what I’m about to see and have to deal with and I surprise myself a little. You see, the main emotion I’m experiencing is not fear or excitement and it’s not sympathy or concern. It’s irritation. I’m annoyed by the situation that I’m being called to help sort out. I know that I took an oath to “make my patients my first concern,” but, despite myself, already I’m thinking that the man I’m about to meet in A&E is a bit of a dick.

A&E is busy, which is not surprising seeing as it’s Friday night, and as I wander through the department looking for Tal, I spy my punter. To be honest, I hear him before I see him. He’s shouting, he’s obviously in an awful lot of pain and he’s obviously very, very drunk.

Tal is in the doctors’ office scribbling some notes and he looks up at me as a walk in.
“The guy round the corner?” I ask, somewhat rhetorically.
“Yeah, sorry about this,” Tal replies. “He’s had 10mg of morphine from the paramedics, I gave him another 10 before I called you, he’s got some Entonox, but as you can hear, he’s still in agony.”
“Hmmm,” I grunt. “And his injuries are where, exactly?”
“Well, he’s lost two fingers and has a deep laceration going across his whole palm.”
“So, all three nerves then?” I enquire, referring to the three nerves that supply the hand: the median, the radial and the ulnar.
“Yeah, we haven’t dressed the wound yet, so you can look for yourself.”
“Cheers,” I say and smile at Tal. I can tell that he’s just as unimpressed with the situation as I am. I think there’s a bond that develops between hospital workers when you have to deal with situations like this in the middle of the night. “Tell me again, what happened to this guy.”
“Well, he says he got into an argument and thought it would be a good idea to light a firework and throw it at the other guy.”
“As you do…”
Tal laughs dryly, “As you do. Anyway, the firework goes off, the flames scorch his hand and then it explodes and blows his fingers off.”
I picture the scene in my head, it’s like something from a cartoon. It would be pretty comical if it hadn’t ended up with the guy in hospital “Why on earth did he think that throwing fireworks would be a good idea?”
Tal shakes his head. “I don’t know, I didn’t go into it. To be honest, he’s so pissed that it’s hard to get any sense out of him at all.”
“What’s his name again?”
“Simon.”
“OK, I’ll go see what I can do.”

Simon is sitting on a trolley with his girlfriend and his Dad next to him. The two of them are sober and obviously really worried. Simon, on the other hand, is not. He’s totally off his face and is singing a Girls Aloud song between cries of pain. I introduce myself, but Simon’s not really paying any attention to me.
“It hurts! It hurts!” he yelps
“Of course it hurts,” I say. “I’m going to give you a couple of injections to help with the pain. They sting a bit when they go in, but it won’t be anywhere near as band as your injury.”
“It’s killing me!”
“Keep using your Entonox, I’ll be back in a minute.” I go off and find a syringe, some chlorhexidine and a small needle. I return to Simon’s trolley and tell him, “Right, I need to take a look at this.”
“I don’t want to see it!” he yelps.
“I need to see what I’m doing.” I respond, firmly. “If you don’t want to see it, close your eyes.” Simon keeps his eyes open and stares intently at what I’m doing. I shrug.

I remove the Incopad that Tal had put over Simon’s had and had a look at his injuries. Simon has lost all the skin and flesh from his middle and ring fingers leaving just the bones sticking out like something from a grotesque film. His little finger was missing altogether and a wide, deep gash ran from where his little finger should have been to the base of his thumb revealing the tendons underneath. It looked horrific. It was horrific.

“Aaargh!” yelps Simon as he catches sight of his mangled hand again. I ignore him and set about cleaning his wrist the best I can.
Simon starts to laugh. “Look at that!” he says as he lifts up his hand. He starts moving his fingers and the visible bones start to flex and bend. It’s a really surreal effect, it looks like something from a horror film. “Ha ha ha ha ha!” comes Simon’s laugh. “I bet you’ve not seen anything like this before, have you doctor?” He’s right, I haven’t. He jabs the skinless bones of his middle finger in my direction. “I bet you’ll always remember me now! Ha ha ha ha ha!”
“Simon! Pack it in! Behave yourself!” comes the sharp, reprimanding voice of his girlfriend. I look up at her and she looks really green.
“Are you OK?” I ask.
She nods. “Do you want to have a seat or maybe get a cup of coffee while I do this?”
“No, I’ll be OK, I want to stay with him.”
I turn back to Simon. He’s not really behaving like someone who, in all probability is about to lose is hand. I shrug. It’s most likely the effects of the morphine, the Entonox (a.k.a. “laughing gas”) and, most of all, the vast amounts of alcohol he’d consumed earlier in the evening.
“Put your hand down and keep still.” I tell him.
By now, Tal had come in as well because he wants to see how I do the nerve block. I talk Tal through what I’m doing, the landmarks I’m using to try and identify each of the three nerves and tell him what dose of Bupivicaine I’m using in each place.
“Right, that’s done now.” I tell Simon. “It’ll take about 20 minutes to start to work, so it the meantime, keep using the gas.”
“Will what you’ve done take the pain away?” asks Simon’s Dad.
I shake my head. “No, it’ll make the pain much less severe, but it won’t take it away completely.”
“What’s going to happen now?”
I look at Tal and he starts to explain the next steps to Simon’s Dad.

I leave them to it and go and jot down what I’ve done in Simon’s notes. My attitude towards Simon has changed since I first took the call from Tal. I still feel annoyed by him and what he’s done to himself, but now I see that how I feel about it is really not relevant to anything at all. This guy’s just lost most of his hand. When he sobers up in the morning, this realisation will hit home. There’s no point in me thinking about what a dick he’s been because every day for the rest of his life, Simon will have to live with his injuries. He’ll have to learn to write all over again, to dress himself to open jars, to do all the simple little things that we all take for granted. Every day, he’ll look down at his hand and he’ll think to himself “Why the hell did I pick up that firework that night? Why was I such a twat?”

Simon’s made his own bed to lie in and he’ll have to face up to that soon enough, my personal feelings towards him is neither here nor there. You see, I can walk away from the situation and not have to deal with it anymore, Simon doesn’t have that option.

I sincerely wish him all the best.

"Don't try too hard, doctor"

I go up to the surgical assessment unit (SAU) in search of Bill. I’ve not yet met Bill and I know very little about him. I know his name, his age and that in order to survive, he’s going to need an operation and, as the anaesthetist on call, it’s my job to try and guide him through it. Despite the fact that Bill and I have never met, as I walk up the stairs, I have grave concerns for his welfare. You see, Bill is 94 years old and the surgeon has told me that he has kidney, heart and respiratory problems. This means that Bill’s future lies precariously in the balance.

I arrive on SAU and it’s packed. I can’t see Bill’s name on the whiteboard so I ask one of the nurses about his whereabouts. The young staff nurse flashes me a smile and shows me where Bill medical records are then points me in his direction, her name badge reads “Emma.” I make a mental note of it, thank her and go and introduce myself to Bill.

The elderly gentleman is lying in his bed with a lady, who introduces herself as his daughter, by his side. I say hello and Bill tells me he’s glad to meet me whilst apologising for not having his false teeth in. I tell him not to concern himself about it and ask him about himself.

I’m learning that part of the art of anaesthesia is trying to build a picture in my own mind about what is likely to happen to my patients both during and after their operation. From speaking to them, examining and looking at the results of a few simple tests, I can get a picture of what the person in front of me is likely to look like one, two, three, seven, ten days after their operation. It’s almost like trying to gaze into a crystal ball and if what I see is not good, I have to do the best I can to change things now, so my patients have the best possible chance.

As I spoke to Bill, I was slightly heartened. Despite his problems, he wasn’t in as bad a shape as I’d first envisaged, and I predicted that with a careful, good-working, regional anaesthetic technique, I may well be able to guide him through his operation.

I set about explaining to Bill and his daughter what I was planning to do and what he should expect. It took a while. It generally does. I was well aware that Bill was coming towards the end of his days and it only seemed fair to me to try and spend a little more time with him and his family. Interspersed in our chat about regional anaesthesia, we also chatted about how Bill would dearly love to go to see the local football team again (he’s still a season ticket holder) and how he couldn’t understand people who put the NHS down because his treatment had been fantastic.

Then Bill said something that gave me cause to pause. He said, “You know doctor, I’m an old man now, and I know you’re going to do your best for me, but what I want to say to is – don’t try too hard.”

At first I don’t understand what he’s driving at, I try and laugh it off and reassure him that, I was going to try very hard indeed – he deserved it after all, but Bill persisted. “I know that things can go wrong and what I mean is that if things do go wrong, you shouldn’t try too hard to put me right again.”

At this point his daughter interjected with, “What my father is trying to say is that he doesn’t want to be resuscitated.”

“Oh” is all I can say. “I’ll respect that.”

I suppose that I was caught a bit off guard because the thought of resuscitating Bill hadn’t really crossed my mind because I was determined that he would not get to a point where resuscitation needed to happen.

Bill interrupts my reflection. “Thank you doctor,” he says. “Please… just let what will be, be.”

As I left Bill and his daughter to prepare theatres, I pondered on Bill’s words. ‘Don’t try too hard,’ ‘don’t put me right,’ ‘let what will be, be.’ As these words rolled around my head, they sounded discordant. They sounded out of place, I got the feeling that they weren’t right, that they shouldn’t even be in my mind. This made me uncomfortable and I found myself initially subconsciously and then actively rejecting what Bill had said. I found the easiest thing for me to do what to ignore those words, put them out of my head and concentrate on finding the sterile vials of bupivicaine.

The trouble was, what Bill was asking goes against just about everything I’d learned. Not only that, it went against everything I was trying to achieve with this with this particular man’s anaesthetic. You see, with the elderly, unwell patients, I have to concentrate much MORE than I do with young, healthy patients. I have to try HARDER, be MORE precise because there’s so much less room for manoeuvre. I can’t “get away with it” if my technique is sloppy or if my regional blockade in not quite adequate.

I’ve realised that with young, healthy patients, you can “get away” with giving a pretty shoddy anaesthetic because they’ll compensate. Anaesthetising 30-year-olds is “easy.” You could train just about anyone to do it in a few months, indeed non-doctors are currently being trained to do just this. Giving a 94-yearold with multiple, serious medical problems an anaesthetic is a different prospect altogether. It’s not “easy” at all. It’s bloody difficult and if you get it wrong, they die.

So I’m sorry Bill, there’s no chance of me “not trying too hard,” I’m going to try as hard as I can because, as I said to you, you deserve it.

A lot has been written about us doctors trying to understand and empathise with our patients but it should be remembered that the “doctor-patient relationship” is exactly that. It’s a relationship, it’s a two-way process and I sometimes think that the other aspect of the relationship, that is the patient trying to understand their doctor, gets completely ignored.

At the end of the day, if I don’t give a good anaesthetic and Bill ends up dead, then I’ll feel responsible. I’ll feel guilty. I’ll go home and think to myself “that lovely man who made me laugh will never ever get to go the football again. His daughter will have to arrange his funeral and bury her father and it’s all my fault. Why the fuck didn’t I try harder? There was something I could have done, but I was too slack to do it, and now he’s dead it’s all my fault. He should be having rehab now and looking forward to catching the end of the season, instead, he’s lying cold and lifeless in the mortuary fridge and I could have done something to prevent this and I didn’t.”

I know that this is how I feel because I know myself. I’m only in my twenties and if I didn’t try hard enough and Bill died, then his memory will haunt me for years. I don’t want this so, Bill, this is partly the reason why I’m going to ignore what you said and I’m going to try as hard as I can.

I've got an idea

Last night, I spent two and a half hours in A&E resus trying to revive people who have got themselves unconscious on drink and/or drugs and whenever I’m in such situations, it strikes me how little these people care about the impact of their actions. They rarely show any remorse for what they’ve done and seem to have little insight of all the problems that they are causing. The last “gentleman” I was dealing with thanked me for bringing him out of his drug-fuelled coma by spitting at me and calling me “fucking wanker.” Sometimes I really wonder why we bother, I really do.

But I’ve had an idea.

I reckon that every person, male or female, who comes into A&E unconscious because of drink or drugs should have the hair one side of their head cut off and a big letter D (for Dickhead) shaved into it.

When word gets around town that the punishment for turning up to A&E in a self-inflicted drink/drug-fuelled coma is that you’re going to look like a twat for a few weeks, maybe we’ll start to see less of this coming through the door on a weekend.

Anaesthetists "don't like talking to people"

When I was working as a general medical doctor, I had a chat with my consultant at the time about my future career. I had pretty much decided that I wanted to switch specialties and become an anaesthetist, but I still wasn’t sure so I was trying to canvass a few opinions. I remember that we had finished the ward round a bit early and the team were having a coffee before cracking on with the rest of the work. The conversation went a bit like this.

Me: I’m still not really sure about what I want to do later on, but I’m thinking of going into anaesthetics

Consultant: Anaesthetics? Why would you want to do that? Is it because you don’t like talking to people?

Me: Not really, I think it’ll be interesting, it’s hands-on and I like physiology

Consultant: Well, it seems pretty boring if you ask me and most people go into anaesthetics because they don’t like talking to people…

His attitude of “anaesthetists don’t like talking to people because your patients are unconscious” is one that I’ve come across several times.

The thing is – it’s a load of bollocks and the truth is somewhat different. I’m as sociable a person as you’re likely to meet and those who know me would say that, if anything, I talk too much. Regarding my job, yes it’s true that I can’t exactly engage in witty banter once my patient is unconscious, but people forget that I do talk to my patients before giving them their anaesthetic – both in the pre-op visit and once they come down into the anaesthetic room. This talk, is crucially important to what I do, both in terms of reassuring the often very anxious patient, telling them what to expect and getting information so I can plan a safe anaesthetic. I talk to them afterwards in the recovery room and on the wards. If I meet them in an emergency situation e.g. in A&E resus, I talk to them there, I talk to their relatives and friends as well– especially those of the patients on ITU. I talk to my staff colleagues, basically I spend a large part of my working day talking to various people about various aspects of patient care and this sharing of information makes everything much safer.

It also stikes me as odd that the “you don’t like talking to people” claim is never levelled at surgeons, after all, they don’t talk to their patients when they’re operating do they? You’ve also got to remember that the conversations I had with patients as a medical SHO weren’t exactly the most scintillating conversations either. They usually revolved around how far the patient could walk, what colour sputum they were coughing up at the time or what their toilet habits were like. I have to say, I don’t miss the conversations that my former consultants were used to having with their patients.

When things start to go tits-up, as can happen very quickly in anaesthetics, talking is crucial to keeping the patient safe. I’ll you an example. I’ve got to anaesthetise a lady with vaginal bleeding so the surgeons can have a look at what’s causing it and try to stop it. From start to end I talked to:

The Obstetrics & Gynaecology (O&G) reg: to find out what he thought was really going on and how long he expected the operation to take.
The patient: extensively, in my pre-op visit to find out about her health and to let her know about the anaesthetic
The Operating Department Practitioner (ODP): to tell her my anaesthetic plan
The theatre team: to let them know that everyone is ready and we can get the patient down to theatre
The patient, ODP and ward nurse: in the anaesthetic room before induction
The ODP and theatre team: to lead the transfer of thee now unconscious patient from the anaesthetic room to the operating table
The ODP: as I stabilise her blood pressure during the rocky first few minutes of anaesthesia
The O&G reg: to let him know that he can start the surgery
The O&G reg: to ask what’s going on as this is taking much longer than the “five minutes he said it would
The ODP: to ask him to help me get another, large-bore drip into this lady and set up a colloid infusion via a pressure bag
The O&G reg again: to ask him to tell me what the hell is going on because this woman keeps tanking her blood pressure to 50/20, forcing me to use inotropes, something I wasn’t expecting to need on this 43 year old woman. He tells me she won’t stop bleeding.
The theatre runner: to ask her to call my reg and ask him to come help me out
The ODP: to prepare to intubate this woman
The anaesthetic reg: to explain what’s going on so far
The theatre runner: to ask her to ask blood bank to cross match us some blood
The ODP: to get some “flying squad” O negative blood and set up the blood warmer
The O&G reg: to get an update on what’s going on – he’s calling his consultant.
Blood bank: to ask how long the cross matched blood will be
The theatre runner: to ask the anaesthetic consultant to attend
The O&G reg and consultant, the anaesthetic reg and consultant: to discuss the problem (D.I.C.) and decide which drugs and blood products we need to give
The haematology consultant: for coagulation advice
Blood bank: to order FFP, get an update on the cross-match and let him know we are sending an urgent sample down.
The whole the team: as we work to stabilise this woman
The ITU charge nurse: to let her know that we’re going to admit this patient to critical care and request that they get a bed ready
The O&G consultant and anaesthetic consultant: as the bleeding eventually stops, we discuss her further care
The theatre team: as we end the operation and transfer the patient to Intesive Care Unit (ICU)
The ICU charge nurse and staff nurse: I explain the events so far and the plan going forward as we settle her on the ventilator
The ICU charge nurse: as a put in an arterial line
The patient’s husband: he’s already been spoken with by the O&G consultant and ICU charge nurse, but I answer a couple of further questions that he has.
The patient: after we’ve woken her up, I explain the events and how she ended up on the critical care unit following her “quick, five-minute operation.”

My point in all of this is just to say that, contrary to what some believe, anaesthetist don’t hate talking to people. It’s good to talk and, every now and then, talking saves lives.

Playing a part

So, I’m on nights again and it’s 4am, when we get the obligatory call from the labour ward. Why is it that labour ward always call at four in the morning? You can pretty much set you watch by it.
The reg and I have had to call in our consultant to help deal with one of those middle-of-the-night dramas that we docs worry about and I take the call from the labour ward.

“One of our ladies would like an epidural, could you come over and do it for her?” comes the voice of the midwife. I tell her that things are kicking off in theatres, but one of us will be over shortly.

“Do you want to go and do it, while I take this patient to ITU?” the reg asks me.
“Sure,” I reply
“Just give me a call if you need a hand.”

I trek across to the maternity unit and make my way to the labour ward and Emily, one of the midwives, greets me as I walk in.

“Hello there,” says Emily.
“Good morning,” I reply
“It’s this lady here,” she tells me as she gesticulates at the board. “It’s her first baby, and I’ve just examined her. She’s 8cm dilated, but she seems to be stuck there.”
“OK, fine,” I say. “Big girl?”
“No, not really.”
“Sensible girl?”
“She seems to be.”
“OK, I’ll go say hello. Hannah’s her name yeah?”
Emily nods at me and we make our way to the room where Hannah is in labour.

A lot is made about the “art of medicine,” and I totally agree that often, practicing medicine is much more of an art than a science. The relationship between doctors and patients is a real example of how much this is the case. Sometimes, I find myself almost acting out a part when I see patients and I’ve learned to play several parts quite well. I can do “chin-scratchingly knowlegable” (with or without actual beard), I can do “gentle and reassuring,” I can do “jokey banter,” I can do “serious,” “stern,” “grumpy,” “dizzy” or “cross.” And I think I can do all of them pretty convincingly. Which of these “hats” I decide to wear with any particular patient depends on the situation.

Generally, labouring women in the middle of the night, don’t want me to sit down with them and discuss their thoughts and feelings about the role of pain in childbirth, they just want something – anything to take the pain away.

I decide that I’m going to be “cheerful and chatty” and I breeze into the room where Hannah and her husband are waiting.

“Good morning! Hannah is it?”
Hannah, looks up at me, briefly stops sucking the Entonox (aka “gas & air”) and croaks a weak, “yes.”
“My name is Dr Michael Anderson, I’m one of the anaesthetic doctors and I’ve been asked to come and see you because you would like an epidural, is that right?” She nods, “Have you read about epidurals?” She nods again, “Good, well there’s just a couple of things I’d like to re-iterate…”

And I go off on my “epidural spiel.” I then ask her a few questions about her health and the pregnancy, scrub up and get started.

As I’m getting the kit ready, I talk to her about herself, whether she’s excited about actually having her first child, baby names etc… etc… As Emily manoeuvres Hannah into the sitting position, Hannah asks me.

“Could you talk me through everything that you are doing?”

This poses a bit of a problem. When you explain any skill to someone else, be it epidural insertion, making a football swerve, cookery, you want what you are doing to go perfectly otherwise you look like a bit of a tit, or in this case, incompetent. You don’t know how things are going to go until you actually do them. Never-the-less, I don’t envisage that I won’t be able to get the epidural into Hannah, so I say “sure thing.”

“Right Hannah, you’re going to feel some really cold liquid on your back now, this is the alcohol prep we use to kill any bugs that are on your skin… OK, now here’s a sticky drape that I’m just going to put on your back… What I’ve got now is some local anaesthetic. What this does is numb this area of your back. It stings a bit when it goes in, I’m afraid, but the stinging will ease in about ten seconds or so…”

“I’ve got a contraction!!”

“OK Hannah, use your gas and I’ll wait. Just let me know when the contraction has passed.”

“OOOOHHH!!!, AAAARGH!!!!” comes her reply, as another contraction takes full hold. Hannah certainly has a good set of lungs on her, but it gives me a good guide as to when to wait. Basically, if she’s not screaming, I’m OK to carry on.

Her cries die down so I say, “has that passed now?” She nods. “OK, I’ll carry on. I need you so curl right up as much as you can now. Put your chin on your chest and really slouch those shoulders down.” She complies. “What I have here is the epidural needle, you’ll feel some prodding and pressure, but you shouldn’t feel any sharp pain. If you start to feel pain in your back, just let me know and I’ll put some more local anaesthetic in… What I’m doing now is looking for the right spot in your back, the spot I’m looking for is cunningly called the epidural space and if you can imagine, it’s about half a centimetre squared and it’s about five centimetres deep into your back…” I feel the give on the syringe I’m holding as my ‘loss-of-resistance technique’ tells me that I’ve found the epidural space – probably. “And there it is… I’ve found the right space, so I’m going to put the plastic tube in now… You may feel funny tingling sensations in you bottom or your legs as this goes in…”

Hannah gives a little jump, “Oooh! I really can!”

“People often feel twinges,” I go on. “Now, I just need to do a couple of tests to make sire that this is in the right place, before we can use this, I need to know that the plastic tube hasn’t gone into your spinal fluid or into a vein…” I look down at the epidural catheter, but already, I can see that the tubing is filling up with blood.

Bollocks. I’m going to have to take it out and do it again.

“I’ve got another contractiioonn AAARGGHH!!!!” shrieks Hannah.

As her contraction reaches its crescendo, I ponder if I should attempt to move the epidural catheter and try to wiggle it out of the vein or take it out completely and try again. On balance, I feel it’s safer to remove it.

“It’s passed…” gasps Hannah

“Ok,” I reply. “This epidural isn’t in quite the right place, I’m going to have to take it out and put in another, try and keep as still as you can for me.” I ask Emily for another epidural pack.

The second time, it goes in fine. I satisfy myself that I’m happy with its position.

“Now, Hannah, I think it’s in the right place now, so I’m going to give you a test-dose of the painkilling mixture.” I check the bupivicaine/fentanyl mix with Emily and give a small dose into Hannah’s new epidural. “OK, that seems to be going in fine. We need to stick this in now, after all this – we don’t want the epidural falling out do we?”

We stick down the epidural and ask Hannah to lie back down on her back.

“Can you lift up your legs for me?” I ask. She can. “Do you feel any different?” Hannah scrunches up her face at me. “Be honest,” I urge.

“I can’t say I do really,” she tells me.
“You’re not meant to,” I say. Now I’m going to give you a proper dose.” I say as I squirt the epidural mix in. “Does it feel cold in your back?” She nods at me. “Like I said earlier, it’ll take about 20 minutes or so to work and in that time, Emily will be checking your blood pressure. But after that, the pain will be much more bearable. I’ll go and do my paperwork, but I’ll come back in a few minutes.”

“Thank-you.”
“You’re welcome.”

When I wander back in ten minutes later, Hannah beams at me. “It’s working?” I enquire.
“Yes, it’s working! Thank you sooo much!!”
“You’re very welcome. Later on today, after you’re baby’s been born, someone from the anaesthetic team will come and see you to make sure that things are OK. But I’m going to leave you alone now, I wish you all the best and congratulations in advance for the new baby.”
“Thank-you” says Hannah again. I leave her room, thank Emily for her assistance and walk back to ITU feeling very proud of myself.

2008 and all that

This post is a few days late as I’ve been too busy enjoying myself. I’m going to wish everybody a belated happy new year and a very healthy, happy and prosperous 2009.

New Year, New Beginnings, but also a time, I feel, to reflect back on the year that’s passed and think about how things have turned out. Have I done everything that I intended to a year ago? Do I think that I am generally happier now than I was twelve months ago? If not, then why? And what am I going to do about it?

I was driving back from my parents’ place the other day and I started to think about the high points and the low points of 2008, and in am award ceremony style, I’m going to tell you about my personal highs and lows of 2008

Inspiration of the year

She’s battling her third different cancer in seven years. She’s lost those close to her but she’s not giving up. Seeing Mrs Campbell slowly pick herself up from her personal low, pull herself through her dark days then slowly get better and eventually leave ITU and then hospital altogether was one of the most inspiring things I’ve ever seen. We all think we’ve got our own personal problems, but they’re nothing compared to what this woman’s been through. When you see someone come through what she’s had to go through, it puts your own life and your own issues firmly in perspective. Stand up and take a bow, Mrs Campbell, you are my inspiration of 2008.

Personal achievement of the year

I’d like to say that passing my FRCA primary exam after only 14 months in the job is my biggest achievement this year but, on reflection, I don't think it actually is. I think that my biggest achievement is that I’m slowly and inexorably becoming a better anaesthetist. In January last year, I couldn’t do half the things I can do now and I feel that as each day passes, I’m getting better and better. Earlier in the year, I had a bit of a crisis of confidence, but that’s passed now, and I feel more determined that ever to try and raise my game and be a great doctor.

Runner up: Passing those bloody exams.

Low point of the year.

Driving home after a shift in which there was a particularly horrific trauma call, I had to pull over to the side of the road because I could no longer see through my own tears. Maybe one day, I’ll post about what happened, but at the moment it still upsets me too much to think about it. This job can sometimes break you right down.

Runner up: MMC 2008-9. Nothing seems to be happening. Nobody’s admitting responsibility for this mess and things HAVE NOT CHANGED. My generation of junior doctors still have no jobs to apply for. The Tooke Report seems to have been deferred until people have forgotten what the fuss was about. The situation on the ground is awful.

Villian of the year

I’m lucky enough to have a great group of friends and to work with people who obviously share the same aim as I – to do the best for our patients however we can. I’ve had the odd disagreement at work, but I’m fortunate enough to have not come across anyone who I would remotely describe as a villain. In the absence of any nominations from my personal life, I’m going to give this award to the evil scum that goes by the name of Robert Mugabe. How many more must die Robert? How many?

Runners up: City Bankers – you guys have a hell of a lot to answer for

People power moment of the year

The reinstatement of Dr Scot Junior after stirling work and public pressure from Dr Rant, Jobbing Doctor, Witch Doctor, Dr Pal among others.

Runner up: Obama’s election

Hero of the year

The bissest prize from me has to go to FashionGirl, my girlfriend. She’s stood by me through some really tough times this year. She was there when I was having some really dark days and she’s been there to celebrate some really good times too. I really admire her in all sorts of ways and think she’s truly fantastic. She’s my hero, without a shadow of a doubt.

Runner up: Dr Harrison

Anyway, those are just the ones I just thought of from the top of my head. How about you? What were your personal highs and lows of last year?

Once again, I wish everybody a very happy 2009!

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.

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.

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.

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.

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.