A week off!

Dr Jr needs to learn not to tempt fate. After that post last week, the week got horrible. Lots of deaths, lots of people who spent a couple of hours going off with me at their side doing everything but achieving nothing. For another time maybe.

So, on the plus side, Dr Jr has a week off, courtesy of my good friend, the European Working Time Directive. Not only shall I use this time to visit the folks and be looked after (imagine that!), but also detach completely from medicine. Glory be eh?

So in the meantime, I suggest you listen to this monster of a tune. Musical brilliance with a video to match!

Why nights are much better than days.

Dr Jr really likes night shifts. Yes, they're 12 and a half hour long (they'd be longer if they were allowed to make them longer). Yes you end up having to deal with ill patients by yourself. Yes you get woken up from moments of snatched sleep by your bleep for the most trivial of reasons ("I have a bag of fluid that'll run out in a few hours time, could you write the patient up for some more?"). It's stressy, disjointed and full of very sick or very mad patients.

Sounds like the perfect horror story, so why do I like it so much? Absolutely no paperwork! By paperwork I don't mean writing in the notes, because that's part and parcel of looking after patients. By paperwork I mean reams of blood cards, piles of radiology requests and meticulous list-keeping. The whole night is entirely about patient care or interacting with patients.

I had a lovely moment with a young-ish gentleman with learning difficulties. He was getting very upset as he had been noisy and the clinical support worker had threatened to call security. I think what she failed to realise is that just because he has learning difficulties, it does not mean he wouldn't get upset at being threatened by security. I sat down with him (on his bed I'll add, with him sitting beside me - sorry infection control, but I will never listen to your complaints about sitting on patients' beds. There's not a jot of evidence and patients much prefer it in my experience. Allegedly there's a paper that says that patients overestimate how long doctors spend with them when they sit on the bed, but that's a whole different story...). We had a very slow conversation; it took him about 15 seconds to formulate a response. He said, in his own way, that he was upset that he had been threatened by security, he was knackered and just wanted to go to sleep now. So I helped him into bed, tucked him in and wished him good night. He was asleep five minutes later.

I'd never get to do this during the day - there's just too much going on, but on nights, you can occasionally snatch a few golden moments like this. And although being thrown into clinical situations can scare you, the whole experience is exhilarating when you get it right, and there is always a reg to offer advice down the phone when you need it, for the times when you're not sure what to do.

That and the fact it's only a four day week. Man, I love nights. And I think it's time to go to bed. Night folks!

(On a side note, Dr Jr was just scared out of his mind when he heard some banging on his first floor windows, only to see a giant brush cleaning them...)

A weekend, hurrah!

Dr Jr has finished his 12 day monster stretch. With last week being horrible owing to the huge amounts of doctors and nurses off on sick leave, I think I'm just a bit relieved to have time to space out in front of my television for a change! Dr Jr also celebrated the end of his monster stretch by inviting a couple of friends round for his one-of-a-kind homemade lamb and mint burgers, with home made chips, homemade potato skins with bacon and cheese for starters and a bramley apple pie with custard for dessert. I would give you my recipies, but alas, I don't have one, I just throw stuff in as a I go along.

Who said British food had to be boring?

When being in hospital is dangerous

Roland Holbrow will not be the last.

Maintaining anonymity on a blog such as this allows someone like myself, working on the front-line, to tell the readers of my blog how things are on the shop-floor. The Daily Mail is a paper that annoys me, simply because it's sensationalist anti-NHS stance means that real concerns are drowned out but the drivel that comes. You'll find a real concern here.

Dr Jr was covering the wards this weekend. Never the nicest of jobs at the best of times, but for some reason, the hospital was heaving this weekend. The bed manager spent most of the weekend trying to close the hospital to new admissions due to bed pressure. On top of that, half the nursing staff phone in ill. What resulted was utter bedlam, for both staff, and the patients in the hospital.

In a hospital, I respect the nurses more than the doctors. A hospital could survive a week without doctors, most of the senior nursing staff are much more skilled and knowledgeable than many of the junior medics, such as myself; juniors (F1s and SHOs) also outnumber registrars and consultants. Even if patients went off completely, the critical care nurses would easily be able to bring them round. Short of internal surgical problems such as a massive bleed, most patients would survive. The reason I mention all this is when half the nursing staff are off ill, 2/3rds of the total patient care goes off too.

Now why are they all ill? Chronic understaffing. Understaffing to the level it's verging on dangerous, but not quite making it. Managers don't want to be in charge of a "dangerous" hospital, it means more work for them, maybe they'll even have to stay 15 minutes late once in a while. So just enough nurses so that all the essential stuff gets done and the actual bits of care that make such a huge difference to quality of stay (such as feeding, cleaning), just don't get done. When even one nurse goes ill, the whole tower of cards crumble, which stresses the working staff out to the point where they need time off. It's a cycle that continues onwards.

With some wards of upwards of 30 patients with just two qualified nurses covering them, Juniorville Hospital was sheer bedlam. The bed manager was trying to clear as many patients as she could, she directly told me "it's safer out on the street than it is in here this weekend". Oh dear.

Meanwhile, in my side, I had already worked all week and was covering 13 hour shifts over the weekend. It got worse when a registrar and SHO called in sick on AAU and I had to end up covering them both. Yes, a lone F1 covering the job of a SHO and a registrar.

Is this normal show across the land? To be so short staffed on the nursing front and requiring medical staff to frequently change firms because they can't employ enough to cover a team over their rotations? It definitely wasn't where I trained. What worries me more is posts like this from PC Bloggs, who presents a similar picture from our on the beat friends over at the local nick. When you see what cuts have done over there, you just fear for the NHS. I don't believe a single word the government says about ringfencing. The axe will come, and when it comes, as always, it's the front-line staff who take first blood. If my hospital is anything to go by, we are in big, big trouble.

Empassioned bleating that restricting junior doctor hours to 48 a week completely miss the point. The problem is the shortage of nursing staff. The 48 hour week doesn't help situations mind, but if you want more work from doctors, where's the money going to come from to pay them for the extra 12 hours a week they'll probably end up working? If hospitals instead bothered to bolster their nursing staff, they would spend less money due to the lack of need to bring in much more expensive bank staff, especially when nursing stress went down and they didn't have to go off ill as a result.

This is when being in hospital is more dangerous. I fear we're heading that direction if we don't stop this cart now and what's worse, I think the brakes on this thing are shot.

The Free Lunch

There's no such thing as a free lunch, is there?

Well for most of the population, that is indeed true. Lunch costs money, figuratively and literally. However, doctors seem to avoid the trend and get an actual free lunch once in a while.

Now, I will admit, it's not necessarily "free" - you're giving your time in return, but as to what you do with that time is really up to you, you can wangle it into the most free of calorific delights. Today, there was a Grand Round. Grand rounds are effectively teaching sessions for everyone from medical student to professor, where a doctor from your hospital presents a topic, usually specialist in nature, with the aim of imparting that knowledge onto doctors from other fields who may never see this condition in their normal practice.

Naturally, as with most educational things, no-one senior would go to them. The eager juniors might. The registrar who is interested in progressing his career in that field might, but a lot of doctors wouldn't. It's not necessarily that they think they're holier-than-thou, but generally because they're too busy to rip themselves away from the ward/clinic/golf course.

However, if you add a nice chicken korma, with rice, naan bread and some mango chutney, then even the radiologists will turn up! But is the lunch really free? If you enjoy the topic that's being talked about, then yes, or if you're like me and the topic is waaaay over your head, you can simply sit at the back and fill out all your blood cards and request forms safe from the nurses and their never-ending stream of requests. So you're fed whilst doing your normal job. Sounds free to me!

Sometimes the job gets your down, but for a busy jobbing junior, especially one who's led by his ever increasing belly, there are times when you've just got to smile.

Big momma

Does this make me look fat?

Dr Jr had a patient today who needed an MRI scan. Alas, he was too big to fit in the MRI machine. The question is, what now?


In other news, Dr Jr bought a new TV. Apparently it's the traditional thing to do with your first paypacket. I'm not complaining!

When medicine fails

Dr Jr had to certify his first death on the wards yesterday.

You could see it as lucky that it's taken a month and a half to have my first death on my shift. You always know it's going to come some day, but the small, optimistic part of your head thinks that it won't come for a while.

Mr Salisbury (name changed of course) had been admitted with neutropenic sepsis secondary to myelodysplastic sydrome. Basically his bone marrow had given up and stopped producing the wide variety of cells needed to fight of infection. He had been discharged from hospital only a few weeks ago, but had managed to pick up what seemed like a hospital acquired pneumonia. On top of that, he was having severe epistaxis (nose bleeds) due to his horrendously low platelet count (which was only 2, when the minimum normal value is around 150). Although we topped him up with platelets and fed him enough antibiotics to kill a small rhino (well, not literally, but you get the idea), the only path for this poor chap was down.

His family and the medical team thought it would be a good idea to discharge him to a hospice to live out his final few days. However, on the day he was due to go, he suffered a haemorrhagic stroke. From being a patient who was, although unwell, perfectly compus mentus, telling jokes and having chats with the staff and his family to a panicked, hemiparalysed man incapable of coherent speech is a horrible enough experience for me, but for the family, I can't even begin to imagine the thoughts and feelings they were going through.

At that point, we put them on the The Liverpool Care Pathway (see my previous post), and within 6 hours, he had passed away. After leaving the family for an hour with the patient, I had to go in and certify death.

It's a completely different experience to check for pacemakers in the morgue. Mr Salisbury was lying in his bed, exactly where he had been for the past couple of days, except he wasn't chatting, laughing or sleeping peacefully. He was dead.

Confirming someone dead is an odd experience. Although you know they're dead, you still have to ask them if they're all right. Although you know there isn't going to be a pulse, you have to feel and listen for one. Eve n though the chest is resolutely still, you listen for breathing. Their eyes may be blank and staring, but you shine a light at them anyway. They remain fixed and dilated. You pinch them and get no response. You save yourself some bother later by checking for a pacemaker now. You look at your watch. What time your watch says defines at what time that person is declared dead.

After writing it in the notes, you carry on your day. While you're busy filling in blood cards, the family are sobbing beside their father/brother/uncle/grandfather. And it never feels quite right to just carry on, but it's what you've got to do.

This is when the job sucks.

Back to business

Dr Jr has been away of late. After having had most of last week off, followed by an awesome weekend karting at the British 24 Hour Kart Race, Dr Jr is back to work again this week.

This week, Dr Jr has been on an endocrine team. Although I'm getting the slightest bit peeved at never having any continuity of care, endocrine has been a good learning experience for me. Endocrine has always been one of my weak points and getting to grips with all the different forms of insulin, SIADH and pancreatic insufficiency has been a useful learning experience. What is nice is being able to get on time every day. Although my colleague who is usually on endocrine seems to never leave before 6.30, I've managed to get all the jobs done, even though we've had more patients on endocrine than at any point since I started. Maybe this is a good sign about how I'm settling in after a month of working.

We also had our first medical student to tend to this week. It's hard to think that only a few months ago I was in her position. It's very odd being the one suggesting which patients would be good to see for a change. It's got me looking forward to them arriving en masse in a few weeks time where not only can I educate them on the finer points of what you really need to know for final year, they can get excellent practice at doing TTOs. It has nothing to do with lightening my workload. Honestly. I'm being serious...