Monday, 23 August 2010

CPR and why I love my job.

Dr Jr has been feeling that his past few posts have been a bit gripey, so maybe it's time to put the shoe on the other foot and explain why he loves his job so much.

I've finished my weekend of nights and I'll tell ya, I haven't run around so much since I started training for a marathon (which I never actually entered, pffft). On the most, it was mainly prescribing fluids and warfarin where the day doctors had forgotten (or been too lazy...) to do. Patients also didn't seem to like having cannulas in either - another chunk of my time was replacing "lost" cannulas or trying to thread in cannulas where site practitioners had failed miserably and left me with a vein more equivalent to a loose thread of string than a large drainpipe.

But weekends have their upsides. For one, although being the only junior doc in the entire hospital, it gives you a lot more responsibility and forces you to make a lot more decisions by yourself. Of course, if there's anything you're unsure of, you can call your reg, but initial management is entirely down to you. A man decided that sleeping peacefully at night wasn't for him and decided to get severely short of breath. The poor guy was absolutely terrified and was begging for help between his gasps for breath. After listening to his chest and it sounding more like an off-key, underwater orchestra than a finely tuned organ for efficient gas transfer, I popped him on salbutamol nebs, stopped his fluids and gave a stat dose of frusemide (sounds much better than furosemide doesn't it?) to pull the fluid out of his chest. 15-20 minutes later, he was calming down and the difference in his breathing was staggering. Within the hour, he was peacefully asleep. Having a little touch of extra responsibility and seeing your decisions make a proper difference really fills you with "feel-good". But that pales in comparison to what happened later.
If only the person who made this really knew...

I had my first crash call this weekend. While keeping some poor lady up at 3am in the morning trying to take some blood to get gentamycin levels that the day docs had forgotten to do, the siren call of my attached "blue baby" (what I've started calling my bleep. Small, noisy, demanding and never satisfied, just like babies, and in a "cute" (bleurgh) shade of what can only be described as baby blue) shouts out "Crash call, X Ward!". Apologising profusely, I take the needle out of the patient (who's had three different people poking her with needles for the last 2 hours to try and get some blood) and sprint across the hospital and up two flights of stairs, passing the AAU SHO who is ambling at a rather leisurely pace.

When I get there, I see I'm the first doc. The nurses have just started CPR and are looking expectantly at the sweating and smelly Dr Jr. It's at these points that you realise you have several metres of detrius in your brain covering the bit of knowledge you need to save this woman's life. After spending a few milliseconds waving away the hazy recollections of that party the night after Dr Jr learnt his advanced life support, your brain engages. I took over CPR, asked the nurses to get the defibrillator and attach the leads so we could get a heart tracing. I asked another nurse to get the adrenaline and amiodarone ready incase we needed it down the line.

Now what Joe Public don't understand is that CPR is rarely successful. On Casualty, ER and the like, you get the impression that someone slides your hands across your chest rather pathetically and a minute later, you're up and chatting, throwing roses and thank you cards at your new-found-hero. The reality is a bit more gruesome. For a start, the success rate is tiny and of those people who go into arrest, only 5% ever leave hospital again. On top of that, you generally end up breaking every rib in someone's body, at least if you're doing it right. The feeling is horrible.

Then there's the "shock". For a start, only a very small number of cases are "shockable". Cardiac arrest can be any one of four heart rhythms, of which only two are shockable. Can't remember which TV program I saw recently that someone in asystole was shocked and came around. No wonder public expectations are high.

In any case, by the time we got a rhythm readout, my reg and the SHO had made their way up and took command. I just carried on chest compressions. Lo and behold, a minute later, the patient's eyes open with a start and she starts moaning. She's alive.

The feeling of satisfaction for doing something like that is simply indescribable. It's at points like these you forget the horrendous hours, the frothing-at-the-mouth consultant biochemists, the smell of various bodily fluids everywhere you go, the patients who try to punch you, the constant wandering around like a zombie trying to find somewhere to sleep and every trial and tribulation you go through on a daily basis and remember:

"I'm a doctor and I can make a difference."

And at that point, you realise that you love this job and couldn't do anything else.

Friday, 20 August 2010

It's all dark and quiet...

Dr Jr is working his first night shifts this weekend. Already I'm having difficulty with it as I don't know exactly how to shift my sleeping patterns yet and reckon I'm going to start this evening dead before it's even begun.

And then when I'm in, the non-stop pitiful bleeps are no doubt going to drive me up the wall. No doubt I'll get bleeped for surgical patients when I'm a medical on-call. No doubt someone will have forgotten to rewrite a drug chart or prescribe fluids.

And who knows, maybe I may even get a nap! Or maybe I'll just never get a chance to sit down. Am I the kind of doctor who uses Zopiclone to get my patients to sleep or will I try and calm them down first? In any case, let's just hope that for the patients I tend to tonight, it's a night shift rather than a graveyard shift...

Tuesday, 17 August 2010

The Liverpool Care Pathway

Today was one of the saddest days I've had, not only as a F1 doctor, but from starting out a fresh-faced medical student. Today, my team signed someone on to the Liverpool Care Pathway.

For those of you who don't know what it is, the Liverpool Care Pathway for the dying patient is an end of life protocol. For patient's whose death is expected an imminent, we withdraw all treatment other than medication to make the final few hours or days as pain free and comfortable as possible.

Now I've never been sure of the ethics of death. It's not something I've ever had to face in my professional career. Many people are heavily against the idea, some feel it "sanctions euthanasia", but seeing it in action as a doctor who is directly responsible for a patient's care really made me think twice about criticisms which I used to think may have an element of justification about them.

The hardest part is the deterioration.
Mrs Thompson (name changed of course) was one of those people who never let life's niggles bother her. About 6 months ago, she noticed some pain in her breast, but of course, didn't complain. It wasn't like her to do so. About a month later, she mentioned it to her son, who, naturally, was very concerned, and badgered her to see the doctor. She didn't. After another a month, her son made an appointment for her and dragged her to see her doctor.

Unfortunately, she had developed breast cancer. And unfortunately, this cancer had spread. There was little that could be done. She went home to spend time with her family.

A few weeks ago, she came in having lost six stone in only six weeks. She had completely stopped eating and drinking. One of the most important things in times like this are calories. The body needs sustenance to stay strong enough to go against the physiological effects that cancer has on the body. After treating her initial problems, she started eating again and things improved.

However, early last week, her appetite disappeared again. No matter what we did, how much her family encouraged her and no matter how often she was told how important it was to eat, she refused. She barely managed half a banana a day. Due to an underlying diagnosis of dementia and her advanced age, it was decided that PEG feeding (putting a tube through her abdomen directly into her stomach) was unfeasible. Immediately moves were made to try and get her home with a complete care package to look after her as best we could.

Unfortunately, these things take time. Over the last 48 hours, she deteriorated massively. On the ward round this morning, my consultant decided that if there was any further deterioration, she would be placed on the Liverpool Care Pathway. By late afternoon, she had become barely responsive and was bringing up secretions.

I phoned my registrar, who spoke to my consultant, who decided that there was nothing more medicine could do. I crossed out all her drugs and wrote her up for medication to take away the pain an nausea, whilst he spoke to the son about what was happening from here.

When you join medicine, you always have ideals of saving patient's lives and making a difference. The feeling you get when you have to simply admit failure is horrible. But it doesn't make a decision like this any easier. Death is an unfortunate consequence of being alive.

Withdrawing all other treatment may seem cruel, however, on reflection, it seems there is a time when everyone, including the junior doctor who's been at the bedside talking to the family and the patient for weeks, just has to let go.

When I go in tomorrow, I don't expect to see her name on the board.

Friday, 13 August 2010

It's the weekend, spend the ash cash?

It's the weekend and Dr Jr will be taking a well earned break from hospital. That said, I have a very good day today on the whole. Much more relaxed. I was still an hour late getting away, but that's more down to me arriving 15 minutes late and having a 1 hour "lunch" break (late in because of having my car towed to the garage and an hour at lunchtime to collect the car).

I signed my first cremation form today. For those of you who don't know, anyone who wants to get cremated needs a doctor to sign them off for it, after death. As this falls outside the NHS, there is a fee which ends up in my pocket down the line somewhere. It's commonly referred to as "ash cash".

Now I'm never sure about the ethics of this. Should I accept money for signing someone off to burnt? Is it ethically wrong? There's several schools of thought. One is that, no, profiting from someone's death is wrong, but then what would we do without undertakers? The other is that it is my duty to provide a death certificate. Anything beyond that is beyond what I am duty bound to do and therefore am doing it as a service to those who are deceased.

It's anything but free...
It actually carries a hefty legal responsibility. I have to be absolutely certain and beyond any doubt that the patient has died of medically natural causes. If there is absolutely any suggestion of foul play, negligence or the patient died of a communicable disease, then I cannot do the form as cremating someone instantly destroys the evidence.

On top of that, if the patient has a pacemaker or IED (implantable electrical defibrillator), it needs to be removed. If I miss it, and they go into the crematorium, there will be an explosion that will do thousands of pounds worth of damage to the cremation chamber and cause unimaginable distress to the family of the deceased. I then, of course, would need to pay for a new crematorium.

So, all that in mind, I think I'll take the money, thank you very much!

Have a good weekend folks!

Thursday, 12 August 2010

One of those days

When it rains, it pours.

Today, Dr Jr was leaving for work. After reversing about 1 metre out of my parking bay, my front suspension decided to snap, rendering the car undriveable. I would suspect that Juniortown's numerous potholes are to blame. It seems like most of my money from my first paypacket will go to repairs and I'm not due my first paycheck until the end of the month!

Once I arrived in hospital (late, of course), the day didn't improve much. I was bleeped almost immediately to come down and write a death certificate for one of my patients on CCU who sadly died last night. It was the first death certificate I have written in a professional capacity - the patient I had gotten to know a bit over the last few days or so. A lovely elderly lady with lung cancer had come in short of breath, with pulmonary and pericardial effusions. They were drained and she was on the mend, but unfortunately, last night, she passed away.

Luckily, I have enough hair to be able to pull some out.
Death is never something easy to deal with and my first patient death came on a day I was already up to the eyeballs in stress. What is most saddening is the fact she has lived a life and now it ends with me signing a piece of paper. To my professional life, that is all she became - some ink on a piece of paper. However, to her family, she was a mother and a member of a very close family. On a personal level, a bit of her will always remain in my mind. Rest in piece Mrs Patient.

Shortly afterwards, I got a very angry call from a consultant biochemist (I'm not entirely sure, are they actual doctors?). One of the patients who we'd just received from AAU had a blood test, which had come back with a potassium of 2.2 - potassium is a very essential salt in the blood, and values too high, or too low can cause cardiac arrythmias and eventually cardiac arrest if untreated. However, I had a loud, angry bollocking on the phone telling me how terrible I was and how terrible my care of the elderly team was for letting this potassium get this low. My pleas of "we've only just received this patient" were rudely shot down with "I've not finished, you will listen to me or I will blame the death squarely on you if she dies."

She was immediately treated and remains completely stable and well. It reminds me of my post from a few days ago about how important a good consultant is - I'm thankful to not be working for this dragon!

To finish the day, I had to walk home. One of my patients pointed out "someone is watering the plants tonight outside." I headed home shortly afterwards. Alas, in my haste to try and get to work in time, I didn't bring a coat or umbrella.

And when it rains, it pours.

Wednesday, 11 August 2010

A weight off my workload

My consultant took pity on little Dr Jr today.

For the last few days, Dr Jr has been the only F1 for 30 patients spread over two wards, one of which is a CCU. The consultant decided this was somewhat taking the proverbial and decided to foist CCU on another F1 (who only had 6 patients).

Not so much anymore!
What's quite amusing is that at lunch, the surgical F1s were moaning about their workload. They have 14 patients between 2 F1s.

I still didn't leave until an hour after finishing, but at least I did a much more thorough job and was much happier with the work that I did do. I'm sure jobbing GPs across Juniorville will be very happy at the new and improved "Dr Jr's discharge letters Mk 2.0"!

Tuesday, 10 August 2010

Consultants: Why a good one is essential for new FY1s

I must say I am a blessed man. I have a roof over my head and a career that will provide for myself and a future family ahead of me (unless of course I do something plain stupid and get struck off).

However, most of my colleagues are in a similar position. Everything is looking good for now. So what about actually being in work?

I am lucky to have a rather superb consultant in charge of our Care of the Elderly team. Not only does he have an undying need to make sure each and every one of his patients gets the best care they could possibly get, but he goes about it in the most amiable, upbeat and pleasant way you possibly could. This being on top of the fact he is responsible for no less than 40 inpatients (in a small DGH) with clinics and suchlike and a very small team to back him up.

It's a pleasure to work with him. He helps out as much as he can, he makes himself available to chat at all hours (one of the first things he did was give me his mobile number and told me to call him "any time"). Most importantly, he treats all his team as equals, himself included. I feel invigorated and eager to work with him. Yes he'll point out what you've done wrong, but in a way you will do nothing but learn from the situation and become a better doctor.


"And ye shall be cast into the firey pits of FAILURE!"
Now, contrast that with a consultant who I was under at medical school. A polar opposite more obvious there could not be. Like most doctors, he cared for his patients, however, his treatment of his colleagues (read "underlings" in his mind) was nothing short of appalling. Regularly reducing the students to tears with his overly brutal approach to junior education, making a mockery of staff and student alike in front of each other and even patients was the order of the day. He wasn't even part of the "old guard" of consultants who were simply "God". He simply was inserting his head slowly into an anatomical region with enough of a chip on his shoulder that the entire product line of Heinz tomato ketchup could not satisfactorily cover it.

Now, for someone like me, it made me work harder. When he told me in an assessment, "I hold no hope for you and I wouldn't count yourself amongst next semester's cohort," (which was apparently quite light going by some of the things he told my colleagues) it drove me to work much harder to go "I'll show you". I promptly merited my OSCEs.

However, it drove some of my colleagues to tipping point. One student who was otherwise high-flying crashed in their OSCEs. It, as expected, turned out to be the one blotch on their otherwise sterling medical school career.

At the end of the day, the work needs to be done, the lessons need to be learnt. As an F1, it is the role of Dr Jr and his colleagues to learn and take point from many of the consultants we will work with in years to come. I'm lucky to have such a good one. If any consultants are reading this, remember, the F1s will be tomorrow's consultants - we don't want to be gods, please don't teach us it's the only way to do things.

Monday, 9 August 2010

EWTD - A new doctor's perspective.

I'm sure we've all heard a lot about EWTD and impressions from many important people across the media and blogosphere. For those of you who don't know what EWTD is, I'll give a brief synopsis.

The European Working Time Directive was introduced in June 2000, with the aim of reducing working hours across Europe to less than 48 hours a week on average. The reasoning is that work related stress is a major problem, accounting for vast amounts of sick leave, and that excessive hours are one of the main contributing factors to this. Penalties are levied for any organisation that makes its workers work more than an average 48 hours per week. This is of course, an average. If you work 96 hours one week, and then none the next, it all balances out. Other rules include having at least 24 hours off in any 7 days, or 48 in any 14.

Excessive hours have driven this doctor
to telepathic communication with the walls...



The NHS, being the slow, cumbersome monolith that it is, were very slow to introduce the changes. Eventually, the NHS fell into line in 2009, taking a very slow route to get there.

There have, of course, been supporters and detractors in the NHS. One of the big worries is the loss of training that this provides. One of the most vocal critics is the Royal College of Surgeons, who claim that it leaves hospitals "less safe". They have consistently said that it means that Consultants cannot be there throughout the stay of their patients and that training for juniors will be much impacted, leading to a new wave of consultants who will supposedly know very little.

As a jobbing junior doctor, my view on this is slightly different. I am working mainly in medicine at the moment. My career aspiration is not fully set yet, but I'm thinking of anaesthetics. But for now, I'm just a lowly FY1.

In my opinion, 48 hours is a decent amount of hours to work, infact, I have no complaints at all. One of the biggest things that seem to worry my seniors is that I won't get enough "experience". Now in a perfect world, Dr Jr would fully agree with that, however, this is simply not how it works.

For a start, I don't work 48 hours a week. I work much more. I don't leave until at least an hour after I'm supposed to finish, sometimes more. Yes maybe that is partially down to inexperience, however, leaving earlier just leaves me more work for the next day.

To address concerns about experience, in the one week I have worked, I can count how many times I've used my "clinical noggin" on both hands. Most of my work involves filling reams of paperwork. Doing the ward round is the most valuable experience of my day (although running around at light speed trying to translate the volumes of gobbledegook coming out of my Consultant's mouth into a succinct output of events on paper is never fun), everything after that is simple paperwork. Blood forms, drug chart rewriting, examination requests, discharges and the like form the bulk of my working day, which requires little medical knowledge or skill.

Most importantly, I wouldn't deem it as "experience". After the first few forms, you learn very little about medicine. You do as your consultant tells you. "Order this CTPA for this suspected PE", "I need FBCs, U+Es and a CRP for this patient", "Doctor, can you write up this patient for some paracetamol please?"

Working more than 48 hours a week simply means I do more paperwork and the trust employs less doctors. I'm stretched enough as it is (I cover two wards of different specialities by myself. No SHO or reg on the wards).

Managers hate it too. It means they need to employ more staff, which of course costs more money. And everyone knows that if it costs money, managers will find a way around it, even if it means overworked, grumpy staff.

Yes, I can understand that further down the line, experience will come more readily, but for the F1, more hours brings nothing but more paper. For people like myself, EWTD allows a work life balance and at least I can be recovered going into work the day after. Does anyone care what the F1 thinks? I hesitate to comment.

Sunday, 8 August 2010

And so it has begun

Dr Jr has started his job as Foundation Year 1 doctor.

After a weeks worth of induction (being told how to lift things and escape burning buildings), we were unceremoniously dumped on the wards, expected to know how to do everything.

So, other than forgetting to order bloods for most of the patients on my ward on the first day, it went quite well! I may have worked an extra hour... or two... every day, but I'm enjoying what I'm doing in any case. Luckily, the nursing staff and senior doctors are pretty darn amazing. Happy, easy to talk to and work with and helpful in my early days where I know nothing, I don't think I could have wished for a better group of people to work with.

Admin is already proving hassle-some - however maybe I'm just thinking this because everything has been so hectic that I've not had time to fill in all these forms. Seriously, how many forests were felled to provide me with all these documents to sign? I don't even know what I'm signing half the time!

But all in all, it's been a good, yet hard, first week. I'm not having to do any on-calls or weekends for a few weeks yet, so hopefully I'll be able to settle in and bed down before the fun really begins. Another plus, none of my patients died! Sadly, it seems like an inevitability that some will, considering the specialty I find myself in, but for now, they remain ticking. Hopefully that won't have changed over the weekend.

Now, I think I must go to bed, my sleeping patters are still skewy since my student days!
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