What is really important?

“Dr. Lin, can I have a word please?”

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

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

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

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

“I’d like to leave the rotation.”

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

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

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

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

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

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

I nod.

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

“Thank you,” is all I can say.

“Have you told the deanery about it yet?”

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

“Good.”

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

“Yes, of course you can.”

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

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

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

Lest we forget

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

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

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

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

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

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

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

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

So what can we do about it?

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

And yet… and yet…

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

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

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

Back to business

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

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

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

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

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

The NHS in the media

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

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

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

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

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

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

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

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

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

Finding my groove

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

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

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

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

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

Best of luck!

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

Stepping Up

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

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

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

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

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

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

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

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