It's nice to have an audience

It’s lovely outside isn’t it? I think we’ve already had more sunny days so far this summer than we did in the whole of last summer. Or the summer before, come to think of it. I’ve been away on holiday and I have to say that it’s been a bit of a struggle to motivate myself and to get back into “work mode” this week.

I’m coming up to the end of my second year of anaesthetics and I must say that my initial concerns about working in the specialty have proved unfounded. Every day I’m at work, I find something new that makes me happy.

For example, today I was working with Dr Burrows for the first time. Dr Burrows has a reputation for being a curmudgeon. He has very high standards and if you happen to say or do anything dumb in his presence, he’ll certainly let you know about it. I guess you could say that he’s quite old school in that way. Rumours say that he’s been stopped from teaching medical students because he kept making them cry.

Anyway, this morning’s patient was in for major surgery and required invasive monitoring. Dr Burrows asked me which parts did I want to do and I immediately said “The central line and the epidural” and went off to get scrubbed up. I’ve put in a fair few central lines and epidurals in the last couple of years and I’m at the stage where I feel just about confident that I can get them into most people.

I set everything up and under Dr Burrows’ punishing stare, I go about placing the epidural and central line. They both go in beautifully first time with no mess and no fussing. Later on Martin, the ODP, says to me “Dr Burrows was quite impressed with you, you know. He said that you were very slick and very professional.”

I smile to myself before replying, “It’s a shame they don’t always go in that easily. You watch, the next one I do will probably be a disaster, but it’s nice to know that sometimes, things go really smoothly.”

And when you do things really well, it’s nice to have an audience.

I heard it through the grapevine...

I can find very few people who think that MMC was a good idea, but still, the juggernaught rolls on, messing up the lives of junior doctors and causing untold stress. One of its so-called "advantages" was to give us a fairer, cheaper and more stream-lined recruitment process so that

a) Hospitals would employ the highest quality junior doctors to look after their patients

b) Junior doctors would have a transparant method of apply for training jobs and be able to compete on a level playing field.

After the MTAS fiasco in 2007, we were told that the recruitment process was going to be sorted out and that the system would ensure that the best doctors are appointed to jobs and that no patients would come to harm because of the changes that MMC brought in.

Do you think that these lofty aspirations have been attained? Let me tell you what I'm hearing through the grapevine.

What the consultants are saying:

“We’re really worried about what we are going to do in August. When the current batch of junior doctors moves on, we’re concerned that there’ll be no one to replace them. The deanery are meant to be sorting out appointing people and hiring SHOs and registrars, but they’re telling us that we’re only going to be given a couple of each. How on earth are we supposed to run a service and an on-call rota with three SHOs and two registrars? It’s ridiculous. We’ve tried advertising for non-training junior doctors, but nobody seems to want those jobs, so we never get any applicants. Who’s going to look after the patients? We’re all really worried. There’s a crisis coming and we don’t seem to be able to do anything to prevent it.”

What the deanery are saying:

“We’ve advertised for people, but we don’t seem to be getting many applicants for the jobs. Some of the people we do get applying for these jobs are certainly, shall we say… inappropriate. We can’t appoint people to positions we don’t think they’re qualified for. For some reason, there’s a shortage of decent quality junior doctors that we can give our SHO and registrar jobs to. All we can do is keep trying to advertise, but I don’t see how things can improve.”

What the junior doctors are saying.

“I somehow have to find myself a registrar job for August, but it’s really difficult to actually find where these jobs are advertised. You used to just be able to look at the BMJ for job adverts, but now you have to search every day on each of the 16 deanery websites. The websites are often un-navigable and confusing. Half of them, you have to register with – which is a hassle - but, even then, they still don’t tell you when they have the jobs out.

“Then the application forms are all different and they take a couple of days to fill in. Then after all that, you know that there’ll only be one or two jobs in the whole area and they’ve probably already been promised to “local candidates” anyway. You just get really disheartened after a while and feel like giving up. I don’t understand why they make it so difficult to even apply for the jobs in the first place. I think it must be some sort of screening mechanism. You know ‘if you can find the application form – then you’ve done most of the hard work and we’ll probably offer you a job!’”

So there you have it - MMC a fair and transparent way to ensure that the best junior doctor are appointed to training jobs. The system is working well!

Did you hear about the one with the GP, the Black & Decker drill and the boy with a hole in his head?

No, this is not some macabre tale from a horror film, but about a story that broke earlier in the week about Nicholas Rossi, a boy who fell off his bike and bumped his head. He developed signs of severe bleeding into his brain (similar to that which killed Natasha Richardson), and the GP, saved his life by drilling a hole through his skull with the only drill he had available.

This story has made me stop and take note for a couple of reasons. Firstly, I deeply admire Dr. Carson, the GP involved, for what he did. Making the diagnosis of an intracranial haemorrhage in these circumstances is not actually very difficult for a trained doctor to do. We also know that to save a patient in these circumstances, you need to relieve the pressure in the skull and this can be temporarily achieved by drilling a burr hole into their skull. Actually doing it is a different matter. It doesn’t take a great deal of imagination to realise that you can do untold damage to someone by drilling into their brain. It takes a cool head, a steady hand and, most importantly, you need to be convinced that you are doing the right thing for the patient on the other end of the drill bit.

Dr Carson is, quite rightly, being lauded as a hero but – here’s the irony – if Dr. Carson had been working as a GP in Britain, or even as an A&E doctor a district general hospital in Britain, he would be being hauled over hot coals right now.

Reading this story in the press, you’d think that these events happened in the deepest, darkest outback and infer that if Nicholas had fallen off his bike in the UK he would have got to a big hospital quicker, making the Black & Decker unnecessary. You’d be wrong, very wrong indeed. Let me explain.

Dr Carson’s rural hospital was 105 miles from the nearest Australian neurosurgical hospital. I work in a hospital about 60 miles from the nearest British neurosurgical hospital. 105 miles by helicopter and 60 miles by road have roughly the same journey time, if anything the chopper will get you there slightly quicker. What I’m saying is that my hospital is effectively just as isolated as Dr Carson’s. We are no closer to the neurosurgeons and their expertise here than he is in Australia. Admittedly, we have some posher drills here, but I don’t think we have a proper craniotomy kit and I’m certain that even if we did, there’d be nobody here that knows how to use it.

My point is that a 13 year old boy with a head injury coming through the A&E doors at my hospital is effectively in the same situation that Nicholas Rossi was in Australia, and, I’ll tell you this much, this sort of scenario isn’t uncommon. In the last 18 months or so, I have seen three people come through into A&E resus with similar symptoms to Nicholas (head injury, altered consciousness and a blown pupil) when I’ve been on call. The difference is that not once have I or any of my trauma colleagues got the drill out. Not once has anybody even suggested getting the drill out.

All three of them died.

I find it quite shocking when I see it written down in black and white like that, but it’s true. (edit - to be fair, two of them had other, severe injuries elsewhere)

The reason that we don’t drill into people’s skulls in my hospital is not because we don’t know what to do, it’s because we’re not allowed to do it. Trust me, if I attempted a burr hole in a patient like Nicholas in our A&E, I would undoubtedly be in huge trouble - even if I managed to save the patient’s life. I would have had the book thrown at me. I would have been accused of “acting outside my clinical competence” of “being arrogant and without insight” of “putting the patient in danger” etc… etc… etc…

I would have no doubt been suspended from working as a doctor and referred to the GMC. And this would be if the patient survived. If the patient died (which, lets face it, is by far the most likely outcome in circumstances like this), I could be struck of the GMC register and possibly put up for a manslaughter charge. Regardless of whether or not the patient lives, very few would be lauding me as a hero. I would be at best a pariah, at worst a prisoner.

I seriously doubt that anyone would have stuck up for me either. Not the anaesthetic consultants, not the A&E staff, not the neurosurgeons, certainly not the lawyers and, if the boy died, probably not even his family would have done.

It’s a sad state of affairs that here, in the UK, we’d rather let someone die than attempt to save them by doing a procedure that we know is required. Once again, my hat goes off to Dr. Carson.

Caught unaware

Another afternoon on call and I’m at another cardiac arrest call. I’ve intubated the nonagenarian in question and am standing, giving the AMBU-bag an occasional squeeze whilst waiting for the medical reg to decide that this poor chap’s had enough and we should cease CPR.

The nurse who’s performing chest compressions suddenly turns to me and says, “Are you humming?”

I realise that I have been. I’ve been humming the same song that’s been going round my head for days.

Caught unaware, I blush a bit and admit, “I suppose so.”

“Are you humming for me or to yourself?”

“Oh, only for me,” I say, “I’ll be quiet now.” The nurse smirks and refocuses on her chest compressions.

Now it’s the next day and the same, unbelievably catchy song is still going round my head. For your information, I’ve posted it in the video clip below. Beware though, listen more than once and you too may find yourself subconsciously humming it in the most inappropriate of situations…

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.

Respect

I’ve been on call and I remember that I’ve run out of milk so, on my way home, I stop at the corner shop to get some.

A couple of local lads who look in their early to mid 30s join the queue in front of me. They’re obviously in the early stages of a night out and are being loud, not rude or aggressive, just loud. One of them clocks me, and I must have been looking as haggard as I felt because he pulls his mate aside and says

“ ‘Ere Jonno, let this geezer go first.”

I’m not in any particular hurry so I reply, “No, no, you were here first” and gesture for them to go ahead.

His mate has turned around to look at me and adds, “Nah mate, after you.”

“Thank you very much,” I say and step forward to pay for a litre of semi-skimmed.

“Thank you very much,” laughs the first bloke as he does a bad impression of my accent. “Are you a student or something?”

“No, a doctor” I say.

Immediately this bloke’s hand comes out to shake mine. “A doctor!” he exclaims and whistles gently. “What are you a G.P. then?”

“No,” I reply, “an anaesthetist.”

He enthusiastically shakes my hand again, “you guys do a great job.”

“Thank you,” I say. “Enjoy your night, fellas” I add as I turn to leave the store.

As I’m walking out a hear his mate saying, “Wow, a real doctor! Can you believe it…” and I smile to myself as I make my way home.

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