Unless it is a matter of life and death

"Severe weather warnings remain in place across the region because of the snow. The advice remains do not travel today unless it is a matter of life or death." said the weather report on the telly this morning.

I sip my mug of tea and peer through the curtains. The world outside is covered in a white blanket and it's still snowing. In the darkness, the snow makes everything look much brighter than normal and, as the snow comes down, the scene outside kind of shimmers. It's like a postcard or a scene from a Dickens novel.

"Do not travel unless it's a matter of life or death," I repeat to myself.

I briefly consider not bothering to try and get to work but I'm covering the Intensive Care unit today, so I think I can safely say the "life or death" thing applies to me. Plus, I know that if I don't turn up, the poor person who's been working on ICU all night will probably have to continue working into the day as well and that would be horrific and unfair.

No, I have to go to work.

My only question is, will I physically be able to get there? I pull on my coat and wellies and go out to survey the damage. My little car is parked on the street covered in about 10cm of snow. The council have had the gritters out and whilst my street has not been treated, the main street has been gritted and I assume that all the other roads on my route to the hospital will have been treated. I reckon if I can get my car to the main street, I'll be able to get to work. Fortunately, yesterday I had the sense to park it at the end of my street, so I'm only about 30m away from the junction.

I turn and go back inside to prepare what I'm going to take:

Hat: check

Coat: check

Gloves: check

Spare jumper: check

Scarf: check

Sandwiches: check

Wash bag: check

Toothbrush: check

Phone: check

Book: check

I pick up my spade as I head out into this particularly cold and frosty morning, crossing my fingers as I do so.

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!

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?

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.

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.

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.

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…

Anatomy of a day shift

A mere six months after the first post in this series, I’m going to continue my Anatomy of… series and tell you about a normal working day.

Anatomy of a Day Shift

08:05

I pull up into the hospital car park, grab my bag and make my way towards the main entrance. When I was working as a junior physician, we started work at 9am. Anaesthetists start work an hour earlier, which gives us time to pre-assess our patients before the operating theatre lists start at 9. I’m well used to the earlier start now and one of the good things about it is that there’s always plenty of space to park in the hospital car park and I don’t have to drive around it for five minutes every day trying to find a vacant spot.

08:10

I’ve decided to come to work “casual” today, so I change into some scrubs before I go and see the patients. At our hospital, there is a distinct shortage of “medium” and “large” scrubs, but plenty in the “XXL” and “gigantic” sizes, but today I’m lucky. I quickly change into the scrubs and head out to find a copy of the anaesthetic rota so I can find out where I’m working.

08:11

Chair Dental

Dr McAndrew

Dr Anderson

Fair enough. I actually really quite enjoy chair dental lists. When children need teeth extracting under general anaesthesia, they can come to one of the chair dental lists. What’s meant to happen is this: The child enters the room with their parent, sits in the dentist’s chair. The anaesthetist gives a quick gas-induced general anaesthetic, the dentist whips out the offending teeth, the child wakes up and then goes home. It’s very quick, it’s very simple and I really enjoy meeting kids, so I find these mornings really good fun.

It takes ages for the nurses to get all the children checked in and prepared so the chair dental theatre list never starts on time. The children have all been seen in the pre-assessment clinic so there’s little point in me going down there and waiting, I just get in the way. I make my way to the doctor’s mess to have some toast and a cup of tea.

08:50

I wander into the theatre and say hello to the theatre team. Catherine is the dentist today, and she’s in a particularly joyous mood. Soon after I arrive Dr McAndrew, the consultant anaesthetist, walks in. I like this man. He’s coming up to retirement and is pretty much the embodiment of the phrase “old school.”

“Look, Michael,” he says to me. “You’ve done this list before with me haven’t you?”

I nod the affirmative.

“So you know that it’s basically fucking boring. If there’s anything else you want to do, or any other list that you want to join that you feel will be more interesting, please feel free to go off and do it.”

“Actually Dr McAndrew, I would quite like to stay and do this. I need to do more paediatric stuff, and perhaps we can do some of my Workplace Assessments this morning as well?”

“Fine, it’s your choice. Tell you what, you can do everything this morning and I’ll just hover in the background and make the occasional sarcastic comment. Show me your paperwork – let’s have a look at some of these forms you want me to fill in.”

The nurse tells us that she’s going to get the first child round and I prepare to give the first gas induction.

The morning passes by pretty uneventfully. The children are well behaved and there were no major dramas. Actually, that’s not true. There were a couple of dramas – one of the children had particularly a particularly stubborn molar tooth. Catherine, the dentist pulled and pulled and huffed and puffed and then the tooth broke and she had to take it out in pieces. She had to stop a few times so I could give the kid some oxygen, but the tooth came out eventually. The last child of the morning was also the oldest (10), so I assumed she’d give me the fewest problems. I was wrong. She got to the stage where she was partially anaesthetised and then her heart slowed down dramatically to the point where it was dangerously slow (down to 32bpm at one point). Dr McAndrew lay the chair flat and I quickly put a cannula into her hand and gave her some glycopyrrolate and this sorted out the problem.

Interestingly, when these things were happening, at no point did I feel out of control, nor did I feel that the children were going to come to harm. These things now seem to me to be run-of-the-mill hurdles that the job as anaesthetist necessarily entails. I guess I’m become more experienced and I know exactly what to do in these situations, hence why these things worry me much less than they used to.

11:30

The other good thing about this list is that it frequently finishes early. This gives me a chance to pester Dr McAndrew into going through a case-based discussion form with me. I have to say, that I’m finding these flipping pieces of paper more and more tedious. Apparently, the forms allow the deanery (who are in overall charge of my training) to tell which are the good doctors and which are the bad ones. I don’t believe this for a second, all they are tedious exercises in form filling. Dr McAndrew tries to make it a bit more interesting and we have a bit of a chat about various neuro-muscular blocking drugs, but really, I just want the piece of paper signed.

12:00

I head back to the Department of Anaesthesia, there’s a lunchtime meeting today, so the consultants, staff grades and trainees gradually filter into the meeting room. Most of the chat is about the pandemic ‘flu and the (lack of) training or advice that we’ve all received. It seems to me that the way my hospital is preparing boils down to “let’s all hope it doesn’t get serious, if we ignore it enough, maybe it’ll all go away.”

12:30

The meeting begins, one of the other ST2 anaesthetists presents a recent piece of anaesthetic research and we have a discussion about it afterwards. Sometimes these discussions just end up with consultants ranting on about their own particular hobby-horse, but today’s was actually quite interesting.

13:00

I pick up my copy of the afternoon list and I’m going to be flying solo this afternoon. I’m doing gynaecology day-case with no direct supervision this afternoon, the patients are all young, healthy women, so I’m not expecting any problems. I go through all the routine pre-op stuff with each of them and then head back to the operating theatres to prepare my drugs and equipment.

13:45

Janet is the ODP working with me this afternoon. After briefing her about the patients and my plan for them, we manage to kick the afternoon theatre list off (just about) on time.

14:15

Mr Jeffries, the consultant gynaecologist, has a SHO and a couple of medical students with him today, so there’s a lot of chatter going on down at the “surgical end” of the patient. Mr Jeffries’ style of teaching is to ask loads of questions at the students in rapid succession and then wait for some sort of response. At first, this seems to bamboozle the students and I smirk to myself as I see their worried faces – I remember being in their position only too well. The medical students are quite bright though, and they soon figure out that by picking just one of the questions that Mr Jeffries fires at them and answering that one, Mr Jeffries would forget he asked the others and then answer them all himself.

16:30

The students have gone now, leaving Mr Jeffries and his SHO to finish the last case. The afternoon has passed calmly and uneventfully, just how I wished. I’ve had chats with Janet, Mr Jeffries and the rest of the theatre team and feel I know them all a little bit better now.

17:10

This is my favourite part of the day. I go back to the ward where my patients are recovering after their operations. They’re all reasonably comfortable and they all thank me for what I did. I wish them a speedy recovery and then go and get changed. As I’m leaving work, Big Ed texts me to see if I’m up for tonight’s pub quiz. I’d forgotten that it was quiz night and was planning on going running this evening. I weigh the options up for a moment then decide that a pint and banter is probably more fun. I text back:

Absolutely! See you at half 7

And then get into my car and drive home.

Global 'Flu Pandemic

As a doctor who spends a lot of time looking after patients on life-support in the Critical Care Unit, I have a vested interest in paying close attention to the reports of the spread of the “Swine ‘Flu” epidemic.

From the moment the story broke on Saturday morning, we’ve had people from the Department of Health and the Health Protection Agency on the telly and radio telling us that “the UK is the best prepared country in the world to deal with a pandemic.”

I really hope that this is true and our preparation is sound, but the thing that’s worrying me is that no one seems to be telling me or my colleagues what the plan is. There doesn’t seem to be any advice about how we actually treat someone who becomes critically ill with swine flu. We haven’t been told what type of protective measures we should take to prevent the in-hospital spread of this flu or how to protect ourselves from it. Should we use special masks? If so, where do we get them from? What should the isolation policy be? What do we do with the rest of the inpatients? Should we come in to work if we start to feel a bit rough? The hospital is pretty much constantly full anyway, so what happens when we get a big influx of admissions with ‘flu? What happens when we run out of beds? What happens when the staff start getting ill?

These are all questions that we’ve been given no official guidance on. Obviously, we’ll do the best we can and try to deal with situations to the best of our ability, but it would be nice to know what sort of special measures or help is available to us.

The thing that’s really worrying me is that nobody in the hospital seems to know the answers to these questions either. The consultants don’t know, the critical care sisters don’t know, and word is that the chief executive only has a sketchy idea about how manage an outbreak in this town.

Reading between the lines, what I gather from the radio is that there seems to be some sort of secret masterplan and I really hope that this is the case. I really hope that a whole chain of events swing into action once we have a suspected case come through the hospital doors.

I’m covering intensive care next week and I want to know if there’s anything different I should do from normal if the medical reg bleeps me and says, “I’d like to refer you a 31 year old man for consideration of ventilatory support. He presented with severe ‘flu-like symptoms after returning from a holiday in the USA on Tuesday…”

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.

An army marches on its stomach

In my hospital, there is nowhere where the staff can get a hot meal. I’ve been told that my hospital is one of the largest single employers in the town and it provides healthcare round the clock, every single day of the year. If you work in my hospital, you are expected to work 8-, 10-, 12-, 13- or even 24-hour shifts, depending on what you do, but despite this, there is nowhere that you can purchase a decent meal in all the time you’re on duty. To make matters worse, because of the location of the hospital, there isn’t anywhere nearby that people can pop out to and get some grub.

You have to either bring your own food in with you, choose from a selection of cold sandwiches and salads at the WRVS counter or at night (if it’s not too hectic) you can sometimes order a take-away to be delivered.

The reason I’m posting about this is because at the weekend I was introduced to a friend of a friend who was a fireman. We swapped stories about our jobs and one of the things that he told me was that at their station, they have hot catered food on site. Not gourmet platters, not fancy Heston Blumenthal-eque dishes, but hearty, hot food that they can buy when they’re on duty.

I know that the catering provision is pretty far down the priority list for those that run the hospital, but I can’t help but think that some sort of on-site hot food provision would make the hospital a happier place to work in. They say that an army marches on its stomach and, considering that the hospital employs so many people day and night, surely this can’t be so hard to achieve?

Satire

The guys over at The Daily Mash are at it again. Apparantly, Stafford Hospital is still "better than homeopathy" despite the following...

Stafford Hospital pioneered the introduction of a doctor-free health system by filling all its senior surgical and medical positions with bean bags, the semi-literate children of Bulgarian immigrants and enthusiastic local dogs.
One of its main innovations was a drive-in morgue which allowed ambulances to deposit live patients directly into the mortuary, sometimes days earlier than would have been the case had they just been left to die in a corridor in line with NHS targets.

You can read the full story here.

How do you cope with stress, doctor?

I've been really enjoying my time away from work. Taking time to pause tends to make me a bit philosophical and I'm going to write about something that I've been giving quite a lot of thought to.

"How do you cope with stress?"

This was one of the questions I was asked at my interview for medical school when I was seventeen years old and it’s something I’ve been pondering recently.

Without a shadow of a doubt, working as a doctor can be incredibly stressful. There have been times during or after emergencies when I’ve been close to losing it completely but, more insidiously, there’s an undercurrent of stress that all doctors have to cope with. How we cope with this is something that is hardly ever spoken about at work, or even outside work. I think there is something quite fundamentally challenging about the environment we doctors have to work in and I’ll try and explain why.

As individuals, people who apply to medical school are very comfortable and happy with health and healthy people. We see good health as being important and something to strive for. Part of the reason we go to medical school in the first place is because we want to help other people achieve the good health that we see as being so important. It’s not a great leap of logic to assume that someone like Slobodan Milosevic wouldn’t have been interested in applying to medical school. So, it follows that the people who apply to medical school are at ease and are comfortable in environments where people are healthy.

As a doctor, you are put in an environment where people are not healthy. You have to work every day in hospitals and hospitals are full of ill people. In other words, you spend the majority of your time in an environment that is the direct opposite to the one in which you feel most comfortable. At any given time, the sickest people in the whole region are right there in your workplace. You’re in an environment when people are so ill that they die. They die every day. You try and help, you try as hard as you can, but they still die. They still die every day. For a person who is most comfortable among the healthy, this sort of environment automatically causes stress. Sometimes great amounts of stress, sometimes so much stress that the doctor can’t cope and ends up having a breakdown or even committing suicide.

Which brings me back to the point of the article – how do we cope? Why don’t all doctors kill themselves? Why do the majority of my medical colleagues honestly tell me that they “enjoy their job?”

It starts in medical school. During your journey through medical school, you learn a hell of a lot of stuff. Medical students will be able to tell you what the sartorious muscle does, why we always sniff when we cry, how to spot cancerous cell down a microscope, at what gestational age the foetal heart beats for the first time, and so on and so on… but I’m now realising that one of the most important things you learn as an undergraduate is how to cope with the hospital environment. You learn how to cope with disease, how to cope with death and, more fundamentally, how to cope with the stress that disease and death will cause to you. You’re introduced to the hospital in a very measured way and, even though we don’t realise it at that stage, it’s at medical school that we learn our coping mechanisms.

But how we cope is not really tested until we become doctors.

Before I started working, I would try and be conscienscious and I’d spend lots of time in the hospital, but at the back of my mind, I knew that I could leave at any time. If I felt unwell I could leave, if I felt tired I could go home and everything would be just fine without me. The patients didn’t need me, their relatives didn’t need me, the hospital staff didn’t need me and I knew that I wouldn’t really be missed if I wasn’t there.

That all changed on my first shift as a doctor. Suddenly, the responsibility was mine. I inherited 25 patients to look after and I had to cope with the fear, the anxiety, and responsibility of trying as best I could to make them all better and get them home. And try I did, but here’s the thing – the work never ends. One patient gets well enough to leave and within minutes, there’ll be a new patient in the bed that’s just been vacated. A whole new person with a whole new set of problems for me to try and remedy and the whole cycle starts again. And this happens again and again ad infinitum.

What I’m trying to get across is that those coping mechanisms that we develop in med school get tested to destruction when we become doctors. Some people’s coping mechanisms stand up, others’ don’t and people have to try and find new ways of coping. I’ve scratched my head a bit and I’m going to try and write about some of the ways that doctors cope with stress.

Working harder

From what I’ve seen, this is the most common one by far. I’ve already mentioned that your work as a doctor never actually stops. There’s always another patient to clerk, another blood test to do, another X-ray to review, another letter to write, another audit to complete, another relative to talk to, another referral to make, the list goes on and on and on. You really can bury yourself in your work to the point that it seems like nothing else matters.

Dr X will say, “I can’t possibly go home yet, I have another four sets of blood tests to do, and repeat Mr Brown’s ABG and make sure everything is prepared for tomorrow’s consultant ward-round…” However, if you scratch the surface a little, you’ll find that the real reason that Dr X is still at work four hours after her shift finished is that Dr X finds NOT working far more stressful than working. You see, when you’re at work, you don’t have time to feel stressed because there’s so much more stuff to get done. At home on your own though… well that’s another story. So Dr X works harder and harder and harder so she doesn’t have to face up to her own thoughts and stresses.
I’m guessing that this sort of thing was more common in the days when junior doctors had to work all day and all night every day and every night, but it’s still very common now in 2009.

Colleagues

Ever wondered why at university medical students seemed to hang out only with other medical students? We just didn’t seem to mix as much with other students did we? It’s partly due to the (relative) intensity of the degree we chose to study, but more importantly it’s that we automatically had a common bond with each other. We had a shared set of experiences that only other medical students could understand, because they were there too. I remember when I was a Fresher and I told a history student that I had to dissect a real, dead person as part of my studies. He was fascinated (and a little grossed out), but he didn’t really understand what it felt like because he wasn’t there. I tried to share with him that I had a nagging feeling that cutting this man’s neck apart was WRONG, WRONG, WRONG because, he was alive once. I tried to tell him that I imagined what he would have been like when he was alive (Jovial? Stupid? Intelligent? Funny? Rich? Poor?) and I had such a massive amount of respect that he’d let me do this to his body after death. But he didn’t get it, he couldn’t get past the part that I “actually cut his neck open – gross!” so I gave up.
This clubbing together of medics doesn’t change after we graduate, if anything, it becomes more marked. Most of my good friends are doctors and it really helps having someone to talk to who’s been through the same experiences. Not only that, you also work with much more senior doctors and nurses who’ve been through it all before, you have role models and people you idolise and this all helps you make sense and cope with events going on around you.

Friends and family

From what I’ve seen, having supportive friends and family is probably the thing that keeps most doctors sane. From a personal point of view, I know that being able to let of steam and rant about the system we work in is incredibly cathartic, even if the person I’m ranting at doesn’t really know what the hell I’m going on about. My friends and family have put up with me when work has made me furious, despondent, frightened or just plain depressed. I know I’m really lucky to have such a supportive social network, whether it’s my Dad saying he’s proud of what I’ve done or it’s my sister telling me that I’m “obviously a good doctor” (like she’d know!), it all helps knowing that they’re there.

Religion

“Though I walk through the valley of the shadow of death, I shall fear no evil.” There can be no doubt that having a faith and a strong belief that there is more to the world than the (sometimes truly horrific) things we see before us helps doctors cope with what they have to do.

Sex

If you work in a hospital for any length of time, you’ll become aware of a strong undercurrent of sexuality with the staff. It’s been there at every hospital I’ve worked. Sometimes it’s understated, but often it’s explicit. There’s lots of flirting, lots of “complementing,” and, if you want it, there’s lots of shagging. I doubt many would admit it but often, this is a coping mechanism. After all it’s much easier to motivate yourself to go to work if you know that a certain medical house officer will be there isn’t it? And it’s much easier to get through the day with thoughts of what the said house officer was doing to you last night running through your head…

Alcohol

Everyone I know has done this, myself included. We’ve all come home and said “I’ve had a REALLY REALLY shitty day at work, come on, we’re going out and I am going to get SMASHED. I want to be so off my face that I can’t see…”
And we’ve gone out and got totally of our faces.
In and of itself, I don’t think that this isn’t really a big problem, but the thing about alcohol is that it can become incredibly destructive. What started out as a big session once in a blue moon after a particularly shitty week turns into going out every weekend and getting blasted. But you’re not doing it because it’s fun, you’re not doing it to have a good time, in fact, you don’t actually enjoy getting drunk at all, you’re just doing it because when you’re drunk, you can forget about the hospital and how being in the hospital makes you feel. Then you find yourself drinking routinely everyday after work, slowly drinking more and more each evening. Then you suddenly find that you can’t get through the day without a drink… At this point your work colleagues start talking about you and how you smell of gin half way through the morning…
Alcohol is insidious, I wouldn’t really call it a “coping strategy” but I’d predict that the vast majority of doctors lie somewhere along the scale that starts with “getting drunk to forget once in a blue moon” and ends with “being an alcoholic.”

Drugs

Doctors doing drugs is a huge taboo, but we know it goes on. The reasons are pretty similar to those outlined above for alcohol. Remember that doctors know more about the drugs they are taking than your average man on the street, we have much more access to uncontaminated drugs, we know what their side-effects are and we know how to hide them.

Other activities

One of the thing I’ve noticed in my career so far is that as junior doctors’ working hours have reduced (currently, a junior doc will work an average of between 44 and 60 hrs every week), doctors are taking more opportunity to “get away from it all.” Doctors now have more time to develop hobbies, be that sports, hiking, travelling, music, painting, charity work, it seems to me that the general chit-chat among doctors isn’t as focused on medicine as it used to be and I believe this is the result of more of having a life outside work.

I appreciate that this post has become very long and really, I’m just jotting down my own personal observations and thoughts but, like I said, how we actually cope with what we have to do is not something that gets spoken about very often.

Do we still need doctors?

"In a world of limited resources can we actually afford, and do we still need, doctors?"

This is the tagline for the debate being held by the North Wales NHS Trust next week. If anyone is in north Wales on Thursday week and fancies popping along, could you do me a favour and let me know what answer they decided on?

Cheers.

On the European Working Time Directive, piss-ups and breweries.

So, in the most unsurprising news affecting junior doctors so far this year, I hear that plans to fully implement the European Working Time Directive (EWTD) for junior doctors have been put on ice for a while. For those who don’t know, doctors in training like me have been exempt from the full effects of the EWTD since it became law for junior doctors in 2004.

The plan was for the directive to be phased in over five years eventually establishing a 48-hour working week for junior doctors by August of this year. I know that the EWTD already applies to hospital consultants but I’m not sure about GPs (maybe someone can fill me in).

I love it that this is being spun as us “getting a choice” if we want to work more than 48hrs. The crucial line in this piece is.

The opt-out means that junior doctors will be able to work four extra hours if
their employer chooses.

Excuse me? I'll "choose" to work more hours if my employer chooses? Trust me, the junior doctors working at the front line will have no choice at all. The “choice” will not be ours, but that of the managers and consultants whose interest is the running of the department, i.e. the service, and absolutely nothing to do with our training.

Reducing the number of hours that each doctor works obviously necessitates changing the rotas that we are on and the numbers of junior doctors employed, but basically, hospital trusts up and down the land have had at least FIVE YEARS to sort it out.

Have they sorted it out? Have they bollocks. Some trusts put together a plan of action regarding steps they would take to achieve compliance, on the other hand, other trusts sat around and did fuck all about it. As August 2009 started to loom trusts “suddenly” realised that they needed to get their arses in gear and do something about the number of junior doctors that were still working 50, 60+ hours every week. They realised that they would face significant fines (£5000 per junior doctor per day, apparently) if they didn’t organise EWTD compliance and panic started to set in. Trusts employed managers to try and sort out the rotas and, to be fair; in some areas they were very successful.

Unfortunately, many trusts now realise that they haven’t planned well enough. They haven’t employed enough doctors or organised changes to how we juniors work. So now we have this fudge situation whereby full EWTD compliance has been put off for maybe two, maybe three years because some trusts couldn’t organise changes to the rotas of their juniors over a five year time span.

The words "piss-up" and "brewery" spring to mind.

Regarding the very separate issue of the impact of the EWTD on the training of doctors in the UK: I’ve already made my opinion known and my views haven’t changed. I do concede that I’m looking at it from the point of view of a trainee in a specialty (anaesthetics) where the training is fantastic and well organised. But, as I wrote before, if other specialties are worried about the training of their juniors, they should really take a good look at what their juniors are actually doing and providing more training time rather than having the attitude that “if the juniors are there all the time, then they’re more likely to see interesting stuff when it happens.”

Things that you don't want to hear when you're coming to the end of a busy night shift...

1. That England is having its worst snowfall this decade and the met office has put out a severe weather warning across most of the country.

I have the sinking feeling that the day shift won't be arriving meaning I won't be going home any time soon... :(

It's oh so quiet...

Something weird is happening today. I’m covering the maternity unit and there’s nothing happening. The only woman on the labour ward has just given birth naturally and there’s nobody else expected in. I’ve literally had nothing to do all day. It’s strange.

Not only is it dead quiet here, I’ve just been over to the main hospital and spoken to the on-call team. Emergency theatres have no cases booked and all the patients on critical care are stable. So the on-call team have very little to do either.

This never happens. It’s spooky. I guess that I’m so used to running around like a rabbit on speed that when things do get really quiet, I start to feel tetchy. I’m going to try my best to enjoy it while it lasts…