Internal Optimist - Medical Student to Junior Doctor Blog

Fading away?

2016-07-22T04:40:00.000+01:00

Hi,

Sadly my blog posts are becoming so irregular I doubt people check in to look for them anymore! I am still alive and doing well, finishing my first year of speciality A&E training in a few weeks, but I feel I should explain why I barely post anymore.

There are two main reasons, the first is time - I am very busy with work and all the things I want to do trying to have a life outside of work (which is a constant struggle!). I have also been doing my membership examination which are needed to become an A&E registrar. This comes in three parts, I have passed the first part and am sitting the second in a couple of months! Sadly revision is also time consuming.

The other reason I have been very tardy with updating my blog is over worries as to what it can be used for. I started it as a way to vent my feelings and frustrations, back when I was in 3rd year of medical school, and back then it was weekly. It was initially aimed at showing what medical school was like for prospective medical students, and aimed at keeping up the hopes of 1st and 2nd year medical students, keeping them looking forward to the clinical years (which were much more fun). As I progressed it basically ended up documenting my journey through, which will hopefully be helpful for people to look through if they are interested. However, this documentation also comes with risk.

I initially started blogging anonymously to avoid breaching patient confidentiality, and to enable me to say what I thought without feeling people were going to judge me for it. However, I am very much aware that being online isn't totally anonymous and it is not too difficult to find out who someone actually is, unless they make a real concerted effort to stop that from happening (which I haven't). There have been a number of cases in the media which have been concerning. For example, a doctors own reflective pieces in their portfolio (which are mandatory to progress to the next year) being used against them in court. It is hugely important for medical professionals (and anyone) to reflect on their mistakes and feelings, but this sets a worrying precedent. Worrying for me as I have definitely talked about (or reflected) on things in this blog which do not make me look good. Another case in the media was that of Christian Solomonides who was taken in front of the GMC and suspended for some of the things he wrote on twitter. He did not use his name on twitter, but was easy to track down (he used his initials...) Much of the stuff he said on there was very offensive, but as someone who also works in A&E I can see why he feels so exacerbated with some of the people who come into hospital. I also feel worried that I have also ranted about staff and patients (though more politely) and question whether this is a GMC-type offence. I guess I also worry that if I share some of my more ridiculous stories this is the sort of thing that this blog has the potential of turning into.

I have thought about trying to tone things down, make things more anonymous or shorter, but I don't really think these things deal with my core concerns about blogging as a junior doctor (especially given the current political climate and press hunger to turn on doctors, some of whom own £500,000 houses, and go skiing for holiday). This is a huge shame, as my last 6 months working on acute medicine have been crazy. There is a mismatched classic 'medical old-school' team with some real 'characters' in it, and the whole job revolves around a crazy book where all the patients details are stored. Given the old-school nature of the consultants there is no chance of this book being upgraded to something a little more digital. Given the fact that all patient information for the whole medical team is in this one tatty book, with no copies, this book is treated as though it is The One Ring. The bearer is all powerful, with people coming from far and wide to look at their wonderful book, and woe betide you if you accidentally lose it in Mount Doom.

I could talk about some of the ridiculous things which have happened over the last 6 months, but given the above, sadly I do not know if it is wise. I will keep the blog online as hopefully the posts from 3 years of medical school and 3 years of junior doctor-ing to date will be useful, and will keep it periodically updated with my progress if anyone is interested. I will keep my eye on how doctors and blogs/new media is dealt with, and perhaps come back properly if the winds are blowing in the right direction.

12 days of Christmas in the ED

2015-12-26T21:10:00.003+00:00

Working in A&E brings plenty of different experiences, here is a selection of true stories from the 12 days run up to Christmas.

On the first day of Christmas, the ED gave to me: a cockroach infestation in resus bay 3

On the second day of Christmas, the ED gave to me: a patient with a baseball bat to the face, and the chance to assist in a lateral canthotomy

On the third day of Christmas, the ED gave to me, a psychotic gentleman after losing a loved one in hospital , the questionable choice to bring the body to A&E due to a flooded morgue to help the patient come to terms, and the dire mistake and consequences of bringing the wrong body up to the ED.

On the fourth day of Christmas, the ED gave to me, many giggling nurses, several confusing PA calls, my name changed on the computer system to 'Bieber', and in inability to change it back until three

On the fifth day of Christmas, the ED gave to me: A patient who had been hit by a bike, a swollen and painful hand, an X-ray showing a dislocated trapezium bone, a referral to a surgeon who wasn't sure what the trapezium bone was, and the feeling that the MRCS must be pretty crappy.

----
I am now, as you can tell, struggling, to keep fitting my recent experiences into this ridiculous format, and will just list the rest. This was a terrible idea to try and do this!
----

On the sixth day of Christmas, a patient presented having electrocuted himself with an iron, wearing a T-shirt emblazoned with 'what doesn't kill you makes you stronger'. The irony was lost on him. Perhaps he was going to turn into a superhero, with a super power of resisting the power of resisting literary techniques.

The seventh day of Christmas was not a good shift. I was called a 'dirty fingering heterosexual' by a furious patient, a very anxious man presented who thought he had cyanide poisoning from eating a bag of apricot seeds from a health food shop and refused to leave, and a patient snuck into the A&E toilet and cut her wrists, barricading herself inside.

The eighth day of Christmas started of promisingly with the ambulance service bringing in a patient coded as 'shooting/stabbing/penetrating wound', exciting the department to prepare for a trauma call, until it turned out it was a man who had dropped a kitchen knife on his foot.

On the ninth day of Christmas, a patient with dementia was bought in due to pneumonia. We were transferring them from the ambulance trolley onto one of the A&E beds, when the patient started taking a poo. The carer, who had come in from the nursing home, shouted 'catch it' and the nurse managed to grab the stick of stool mid-air out if instinct. With her bare hands. Merry Christmas...

The tenth day of Christmas was more positive, with a patient telling me they had named the pulmonary embolism they had developed after surgery 'Jeremy Hunt' as it was a "potentially fatal clot" and a drag queen attended with mallet finger after getting their fingers stuck together while gluing on their eyelashes.

They eleventh day of Christmas was a day of detective work. A child presented having eaten berries from the garden of an unknown origin, but the mum had bought in the leaves from the plant (if only I had a botany degree as well, but good ol' google has the answers as always if you look hard enough). There was also the interesting conundrum of a patient presenting in acute alcohol withdrawal which can be very dangerous and even fatal unless the patient continues drinking, but with the added problem that she had been given a bail condition that she couldn't drink any alcohol, due to an assault, and if she did she would go back to prison.

The twelfth day of Christmas started well, with plenty of gifts to the department of tasty food from the local Jewish ambulance service (Hatzola) and Muslim communities (interestingly we had many more gifts from groups that were not Christian), but then was ruined when I mistook the medical consultant for a patient who had come in with solvent abuse induced hallucinations, and told her that she needed to pull her act together and that we were not going to give her the glue back that we had confiscated... I am going to have to keep my head down until the New Year!

Procedures and nights

2015-11-08T20:12:00.004+00:00

Hi,

Sorry for the poor rate of posting - I have been very busy but that is always my excuse. I am now in a training post as an emergency medicine trainee. The hours are pretty rubbish, and I am working every weekend this month, but I love the job. I get to see a complete range of diseases and people every day and get to do a lot of different things.

I am on nights this weekend, but over the last week and this weekend I have seen people ranging from a 45 year old woman with vaginal bleeding 4 weeks following her last period (quickly diagnosed as her next period and discharged) to people in cardiac arrest and with severe burns and explosion injuries following bonfire night mishaps.

I really like the procedural side of A&E, and the chance to get away from the constant push to see and discharge people before they 'breach' the 4 hour wait and sit in a room for 20 minutes and do some suturing or put a joint or broken bone back in place. Yesterday night (or this morning more accurately) someone came in with eye pain for 3 days following angle grinding some metal without eye protection. I am not an expert with the equipment needed to examine eyes (called the slit lamp, and often seen at opticians) but I could see a small piece of metal just over the iris (similar to the picture below)

Metal piece in eye, picture taken from Opthobook.com

I have not taken things out of the eye before, but remember being taught how to back at medical school. The registrar on had also not done this procedure before and was caught up with a sick person which we couldn't get venous access on, and was trying to gain access with the ultrasound machine. I thought I would have a gentle try and if failed, would have to get the person to come back to see the specialist tomorrow. I bent the end of a needle and managed to use that to get the metal out of the eye. Very rewarding, but nerve-racking, poking the end of a long needle towards someone's eye and repeatedly telling them they have to hold very still!!

I also had a patient last night/this morning who had abdominal pain and a large mass at the lower part which felt like it could be the bladder. I have not had any ultrasound training but am always in awe of the more senior A&E doctors who can rock up with the ultrasound probe and diagnose heart failure, PE, pneumothorax and so on in seconds at the bedside. I thought I would have a go with the ultrasound (no radiation, nothing to loose) to see if I could see if this was the bladder.We normally have a special machine called the bladder scanner to measure for bladder volume but our department's one broke 6 weeks ago and is still apparently being repaired... Positioning the probe over the bottom of the abdomen I could see the large circular bladder, and using the measuring tools on the USS it was massive. We put in a catheter and 1 1/2 litres drained out. Although this is a very simple thing, it was very rewarding to be able to work out how to do something, make a diagnosis and be able to make a clinical difference to that patient.

I also managed to do a special nerve block to the femoral nerve for a lovely 90+ year old lady with a hip fracture last night/this morning as well!

As you can see I have been doing loads with my shifts, and feel like I am learning lots of new useful skills. Sadly I have one of my professional exams coming up and having sunk over £300 into it I now need to spend much of my free time revising, as it is coming up next month! It seems there is no rest for the wicked.

Finally, I really hope that as junior doctors we do not need to strike, and the BMA and the government manage to re-enter negotiations, but given all of the poisonous rhetoric being put out but Jeremy Hunt, and the hatchet jobs appearing in news papers (most recently today in the Mail on Sunday) I think that it may well come to that. This is a huge shame, but a small price for us as a country and profession to pay for continuing the good work that the NHS can provide and preventing the destruction of the NHS and many doctor's lives.

Politics

2015-07-27T20:23:00.000+01:00

Hi,

I haven't usually bought up politics on this blog, but that definitely doesn't mean I am not interested. The current government stance and rhetoric on the NHS and doctors contracts is very frustrating. I could go on about it for paragraphs as many (much more eloquent) people have done, but I will just recommend this blog by juniordoctorblog.wordpress.com which I feels summarises the governments response well, and critically analysis it (with referencing). I cannot thank the blog's creator enough for putting the time and effort into creating a much better thought out, and much more thoroughly researched piece than the current government.

God's balls

2015-07-14T22:36:00.002+01:00

Hi,

Wow, it has been a long time since I last posted. This job is quite busy, but isn't busy enough to give me an excuse. I suppose I have just been distracted by other things going on in life.

I am on paediatric surgery at the moment, which is a big change to anything I have done before. I was pretty scared when I came into this rotation as I didn't have any paediatric experience previously, and it has taken me a little time to get my head around things. On surgery I am the only F2/SHO and there is usually a registrar and consultant on at the same time. As with most surgical specialities, they spend much of their time in theatre so I am left on the ward trying to work out what to do with my patients. Fortunately at the start of the rotation the general paeds team, who share the paediatric hospital with us, were very helpful. Sadly in the last month or so, due to politics which is well above my paygrade, they have been distancing themselves from my team so I have had to make do much of the time, but fortunately are still around in case one of my patients is genuinely ill. I am getting to spend some time in theatre as well, though, which is quite interesting, but I don't think surgery is the profession for me. The initial cutting is exciting but then all the searching around and stitching up layers is not!

The reason for coming to post today was an absurd situation I found myself in, and I felt I should share it. A 9 year old patient had come in yesterday with an acutely painful testicle. We were worried that this was testicular torsion - a surgical emergency which results from, surprisingly, your testicles getting in a twist. His mother was not keen on him having the surgery and it took about an hour and a half to persuade her that this was necessary. The surgery was performed overnight and found a torted hydatid - a little extra bit on the testicle which is the remains of the female reproductive organs (from when the boy was a foetus). This has no known function and is not important, and doesn't need surgery if it is diagnosed before the operation. The problem is, having a twisted testicle is an emergency and you don't want to faff about trying to work out which one it is with ultrasounds and the like if you are unsure - leaving the testicle twisted for too long will result in it dying permanently. In fact there is a surgical 'saying' - ""Testicular pain - don't engage brain"

The next day, the child was well and happy to go home, but the mum was not happy. I had been left to review this child, as the consultant and registrar had gone to theatre for a different case. The mum was upset that we had operated on the child and found nothing wrong, and upset that we had removed the dead hydatid of Morgagni which had been causing the pain. The reasons for this were that she knew that there was no problem with her child's testicle (hence why she was initially refusing the operation) because she was very religious, and she knew that God wouldn't want to harm her baby; she was upset that we had carried out the operation as she felt that God had been testing her faith and she had failed, showing she didn't trust in him to provide for her; and she was upset that we had removed the dead twisted tissue (why did God put it there if it has no use).

A picture found from the internet of an ultrasound of someone's testicle with the face of the Egyptian god of male virility in it

First, I was glad that the consultant was not around, as I would probably not hear the last of him being compared to God in 'providing' for this woman. I wasn't too sure how to address her concerns though. I tried to explain that bad things did happen to kids (a point helped by being in the middle of a ward full of sick and disabled children); I tried to point out that perhaps the presence of the hospital was a way for God to provide for this woman in her time of need; and tried to convince her that we had no known function for this tissue, and its removal shouldn't affect her son in any way. She was not amused by my attempts at explaining things and kept trying to drag me into a theological argument. All of this was watched by the husband who was clearly on 'my' or the medical establishments side with regards to the need for the operation, but not keen on speaking up. I feel a lot of the passionate arguments the mum was giving were more for his benefit than mine. I am not a religious person by any means and was trying to keep things civil, but it took me an hour and a half to escape.

An hour and a half!

I was called back twice for questions about wound management by the nurses, which just turned out to be more theological arguments over why God wouldn't want to hurt this boy, and how he must have a special plan for the hydatid of Morgagni, if only we would wait and see. I felt that these recalls were likely due to the husband arguing things with the wife, so she would bring me back and argue them with me. Not ideal given we have about 20 other patients in the hospital at the moment to look after. The third time the nurses called me telling me she just had a couple more questions before she left, I asked them to tell her that I would happily come down if she promised not to talk about God anymore, and if she had any more questions of this nature then perhaps she should take them up with the hospital chaplaincy service. Unsurprisingly, she changed her mind and decided that she didn't need to speak to me any more. I will have to go back tomorrow and ask the nurse if they had to call the chaplain as an emergency to explain the reasoning behind an omnipresent, omnipotent, omniscient, benevolent God.

PornBomb

2015-04-01T22:41:00.003+01:00

Hi,

Changing jobs today, and I am pleased to be moving on. As ChocolateAndCream said on the previous post, GP seems pretty love or hate, and I really don't think I liked it. This could be in part to the practice, which I felt abused its junior members and made us perform most of the work, having to stay late, but even without this I still don't think I would have really enjoyed it that much. The last day was hilarious, though. I had gone to hang out with the admin staff over my lunch break to say goodbye to everyone, and was helping one of the admin people open up letters to the GP. They get hundreds a day, as despite it being the 21st century email doesn't seem to have caught on (but fax has become quite popular).

One of these letters was suspiciously bulky, and addressed personally to one of our partners rather than just to 'GP'. Most are thin and typed, as they contain a few sheets of paper about a patient's hospital appointment, but this one was handwritten. I opened it cautiously, half considering that it may be full of anthrax, or some kind of bomb from a slighted patient. Inside I found an A4 sheet with both sides filled with scrawled handwriting, and about 100 pieces of pornography cut out from magazines and papers. The handwritten scrawl was difficult to understand, but seemed to say, in summary, that the patient was very happy with the care he had received from this one of our partners, and was enclosing a selection of 'presents' to thank him inside.

A strange goodbye to GP, it wasn't all bad, but I am going onto paediatrics now and am looking forward to the challenge!

Open the floodgates

2015-03-29T23:50:00.003+01:00

Hi,

I often see a lot of unusual presenting problems on GP, and having watched a couple of those Channel 5 programmes "GPs: Behind Closed Doors" I can certainly say that there doesn't seem to be much exaggeration...

On Friday I had a very strange day. The roof was leaking a strange yellow coloured fluid quite heavily for the morning, and I couldn't be moved to another room as there were no others available. We are part of a multi story complex, so I was worried it might be urine, but I definitely hope it wasn't! It certainly didn't have the smell at least. Either way, trying to explain the hodgepodge of buckets I had created on the floor to try and collect as much of the (large) quantity of water which whooshed down every 5-10 minutes, and all the paper towels I was (unsuccessfully) trying to use to dam the errant fluid from the patient's shoes.

In this ridiculous situation I had to consult all morning until I got to move room (when one came free) in the afternoon. Among the other patients, I had a lady who was convinced that she had high blood pressure because every time she touched something after walking for a while at home she got a shock (feeling all the high pressure coming out of her body). It took all my persuasive powers to convince her that her new carpet (Sherlock Holmes right here!) and the phenomenon of static electricity was to blame. This consult was followed by a lady who was concerned as sometimes she woke up and her arm felt as though it was 'dead' and she was worried it would fall off. She had recently come to the UK from another country, so trying to explain that this was a normal phenomenon was complicated by trying to use a telephone translation service.

I was getting quite frustrated throughout the morning, mostly due to the roof leaking all over me and my patients rather than due to the patients coming in, and my final patient must have sensed this. After talking about their problems they asked me if I had ever considered Islam as a religion as I was a very good listener. I didn't really want to get into a religious discussion and tried to deflect the question, as I wanted to get off to lunch by this point. Stranger still, in the afternoon after dealing with another patient's issues (a ganglion of the wrist) she handed be a leaflet on Christianity and asked me if I had accepted Jesus into my life. Perhaps it was the weather, or the time of year, but you couldn't have written a better script for an absurd day!

Either way, I only have a few more days of GP life left, and then I am onto my next placement. I am looking forward to a change in scenery and pace!

In other news I have been offered a training post in Emergency Medicine for the next years, which is very exciting. This is what I think I want to do with my career in the future, and I am looking forward to getting back to the exciting hospital medicine!!!

Pregnant but you don't know it

2015-03-24T22:44:00.002+00:00

Hi,

Had a patient present a few weeks ago who reported she had not had a period this month. On questioning she was adamant she couldn't be pregnant as hadn't had sex recently, but agreed to do a pregnancy test for me. Unsurprisingly this test was positive. This left her in a difficult situation - she wanted to complete her education and her religion advised her against abortion, but she really didn't want to complete the pregnancy. After talking through the options I gave her referral details for the midwives and the abortion clinic, so she could choose which option she wanted to refer herself to after discussing with her family.

Today she came back, even more upset. She had decided that she didn't want to continue with the pregnancy and had attended the abortion clinic. As part of their work up they performed an ultrasound scan which revealed a 7 month old foetus (thank god for the scan!!)! This effectively took the choice as to what to do with the pregnancy away from the girl as this is far too old to consider abortion. We talked for a long time, and it turned out that she hadn't actually had periods for all this time, and had had unprotected sexual intercourse while on holiday in Europe at about the correct time. Eventually she came to terms with the situation.

3 main points from this:

1) This apparent virgin pregnancy was sadly not what it seemed

2) Some poor European man has a child he will never know about

3) Always examine the abdomen! If I had examined her I would have felt the baby!

As the streets might have said "You're pregnant but my gosh you don't know it" - and evidently neither did I! [Apologies for linking to terrible piece of music]

Heart block and the breakdown of marriage

2015-03-19T14:01:00.004+00:00

Hi,

Another little hiatus to blogging as I was on holiday! Coming back, I want to share an explanation of the different types of heart block using the breakdown of a marriage as a metaphor. I heard this explanation recently and want to share it with you mainly because I found it funny!

Science stuff - heart block is a problem with the electrical conduction of the heart, which delays (or blocks) the normal signals progression through the heart muscle. Depending on the degree of this blockage you get different appearances on ECG, which are 'graded' into different types of heart block. Simplistically, the greater the level of heart block the more dangerous it is. Heart block is measured by the relation between the 'P' wave of the ECG and the 'QRS' complex of the ECG - see image below

P wave comes before QRS complex as shown here

The metaphor is a marriage and the washing up leading to the breakdown of this marriage.

Normal heart:

A good marriage with a slightly lazy husband. In this he sadly needs to be reminded to do the washing up every day. The P wave shows the wife having to remind him to do the washing up, and the QRS is him doing the washing up. At the early states of marriage he is good and does it every time promptly when asked. See normal ECG below:

Nice short regular spaces between P and QRS. Not much nagging needed!

First degree heart block:

Now comes the start of the marital breakdown. First degree heart block has a regularly prolonged period of time between the P and QRS waves. Here the hubby is getting a bit more lazy - every time he is nagged to do the washing up he delays it before doing it, perhaps leaving it overnight until the morning before doing it. This is due to poor conductivity of the electrical impulse in the heart slowing things down.

Look at those big gaps between the P and QRS. Leaving it to soak all night is not a valid excuse!

Second degree heart block - Mobitz type I (also known as Wenckebach):

As things start getting worse in the marriage the husband now sometimes misses doing the washing up all together! In this situation the ECG shows a prolongation of the interval between the P wave and QRS complex each beat until it gets so long there is no QRS complex following the P wave at all. After this missed beat, the interval becomes short again and the process repeats. This is the husband becoming lazier and lazier, leaving the washing up longer and longer until he just cannot be bothered to do it. This obviously leads to an argument and then he has to buck up and he gets on with doing it properly again, but then becomes lazier and lazier until he misses another washing up. See ECG below

See the interval between P wave and QRS complex getting bigger until the whole QRS is missed, then repeating

Second degree heart block - Mobitz type II:

Here the husband just misses doing the washing up every so often because he is out of the house (with friends, with a mistress, we will never know). Here the interval between P wave and QRS complex is kept the same (perhaps due to guilt) but there is a regularly absent QRS complex. ECG is below

Intermittently the P wave is not followed by a QRS wave as it should be

Third degree heart block (complete heart block):

Here there is no association between the P wave and QRS complex at all - P waves are happening and QRS complexes are happening but they are not linked. The wife has become fed up with the husband and has left him - they are both doing their own washing up independent of one another in different houses.

Here you can see regular QRS but no relation to the P wave - some P waves fall before, after, or on other parts of the ECG.

That's the stages of heart block explained as though through marital breakdown. I thought it was quite funny and helpful to help remembering which is which. I hope you find them helpful too!

Definitely not pregnant

2015-02-20T21:52:00.000+00:00

Hi,

Had a flummoxed patient come in to see me today after she had been started on the progesterone only contraceptive pill (or mini-pill) three months ago. She had been asked to come back in to assess how she had been coming along with this medication and to prescribe her more. After talking about how things were going with the pill, I offered to prescribe her a years worth, so she didn't keep to have coming back

"Oh, don't worry about that doctor, I've got plenty"

Confused, I asked what she meant, as her three month period was almost up

"Oh, I have lots left thanks. They gave me all of the stock the pharmacy had - they even had to get me to come back later as there wasn't enough to give me. I have a whole bag of packets left"

I was confused as to what had happened, but on further probing it turned out that there had been confusion and the script which had been issued by us for 84 pills (3 lots of 28 = about 3 months) had been cashed in by the pharmacist for 84 packets.

~6.5 years worth of contraception.

Mammaries

2015-02-17T22:42:00.002+00:00

Hi,

Awkward consultation today where a middle aged women wanted to have a breast reduction. This is something difficult to negotiate at the best of times, as it is all about finding where that line between health benefits and cosmetic lies, but it was made so much more difficult by the fact that when she wasn't referring to her breasts as 'the twins' she was referring to her 'mammoth mammaries'. Her pointed enunciation of the letter 'm' throughout these words, and the serious note she was clearly trying to portray by using this clearly medical phrase made it difficult to complete the consultation with a straight face.

In the end we decided that it would be quicker and easier if her boyfriend paid for the surgery

The Great Cholesterol Con?

2015-02-14T10:48:00.003+00:00

Hi,

Had a recurrent difficult consultation over the last few weeks - a lady had had routine blood tests done as part of her NHS health check which had shown a raised cholesterol. It is generally accepted (and pretty widely known) that high cholesterol levels lead to an increased risk of diseases such as heart attacks. This is based on a wide body of evidence from multiple studies and meta-studies backed up by government organisations such as NICE and mostly by the most important source of all - Wikipedia.

This lady had read a book called "The Great Cholesterol Con" which suggests that cholesterol is not linked to heart disease at all, and there is nothing to gain from lowering it at all. For this purpose she had started a "sausage diet" where she ate 1-2 sausages every meal, breakfast, lunch and dinner, along with the rest of her food. Predictably her cholesterol was crazy high. I tried to talk her through the evidence behind the ideas of lowering cholesterol, but I hadn't read the book so couldn't do this very effectively. I asked her to come back the next week so I could have some time to do some research. She was a little bit annoyed about this - she felt as a doctor I should know all this already, but agreed to return.

I read up on the arguments in the cholesterol book, which are based around inconsistencies in the Framingham Heart Study which suggested that as your cholesterol dropped, your risk of heart disease rose. It seemed as though this book was very selective in the data which it displayed to portray its arguments (well summed up by this review of a similar book) and ignored huge swathes of evidence which did indeed suggest high cholesterol levels (rather than just all cholesterol) are bad for you. You obviously need some cholesterol (and some salt, sugar, etc) but having too much can be a problem.

I collected up all of my research and information and bought it back to the next consultation with this lady. She was having none of it, and told me I had been taking backhanders from the statin producing pharmaceutical companies to peddle their wares. I tried to explain that as the patents on drugs such as Simvastatin had expired there would be no specific drugs company to try and pay me off, but the more I tried to disagree with her the more angry I made her.

This was a loosing battle - I guess all we can do is display the evidence to the best of our ability and let people make decisions for their own health based on that. It was just upsetting that this wasn't a concious decision to damage her own health (like someone who smokes 40 a day, knowing full well it is bad for them) but a misinformed decision to try and help her own health, possibly guided by someone more interested in book sales than helping people. That said, she is coming back next week for another round of discussion, so wish me luck!

Mistakes

2015-02-08T20:57:00.002+00:00

Hi,

Awkward moment with a patient on Friday. He had come in with a strange looking rash on his hands and face. It was strange looking and I wasn't too sure what it was, and told him it might be a non-specific viral rash and I wanted to get one of my seniors to look at it. He replied that he thought it was hand, foot and mouth disease after searching on the internet. I assured him that this was rare in adults, and went off to ask one of the GP partners to have a look.

A cursory glance later, the GP told the patient that it was definitely hand, foot and mouth, a viral infection which will resolve itself, and isn't anything to worry about and left. The patient gave me a look of scorn and then followed the partner out of the door

I guess that makes us 1-1 Dr Google...

Nuclear war

2015-02-04T20:48:00.000+00:00

Hi,

Today I saw a lady who had become obsessed with the fear that we might have a nuclear holocaust this year. What do you do with this situation? I tried to explain that it is unlikely, but I couldn't say that it certainly won't happen. What with all these problems in Ukraine and the Middle East, she told me that perhaps I should be more worried and left.

Perhaps she is right!

Fertility

2015-02-02T20:16:00.001+00:00

Hi,

Really tough consultation today. A 44 year old lady had been coming to our practice for a few years trying to get pregnant. She had got a text asking her to make an appointment with a doctor about her recent blood test results, and came in to see me

Due to her age, she wasn't eligible for NHS assisted contraception during the last few years, and had been in and out of the surgery getting blood tests, trying to stop smoking and reduce her weight in order to improve her fertility. The blood results she had come in to hear about from me showed that she was going through the menopause and couldn't have children now.

This was terrible news to break to her, as she really wanted a child. I think she had been in denial for some time, though, as she hadn't had a period in about 6 months. I spent over an hour talking with her while she alternated between crying and shouting at me - she felt that we had let her down and let her time run out. Being exposed to that raw emotion was scary, and I was aware that towards the end I had 5 people waiting to see me in the waiting room who could hear all the shouting and sobbing coming from the room.

Being a GP can be emotionally draining, especially when you are questioning whether your team may be in the wrong...

CBBC skills

2015-01-31T18:25:00.000+00:00

Hi,

On Friday one of my patients was a 3 year old kid who had come in with an ear infection. After having a chat with the parents and a playful examination of the kid I reassured them and went to send them home. The mum was really impressed - she told me that her child was usually really shy of the doctors and wouldn't let them examine hum at all.

For a moment, I was secretly smug. I am the child whisperer! She quickly deflated my bubble and explained that it was probably because I looked like one of the 'silly CBBC presenters' and wasn't scary like those 'other older strict doctors'...

Well, as long as the kid doesn't vomit on me, I will take it...

Dr google

2015-01-27T17:26:00.000+00:00

Hi,

A patient came in today with calf pain he had had for a week after falling off of his bike. After a google to come up with the possible causes for this, he was adamant that he had acute compartment syndrome. This is a medical emergency where the trauma to the limb causes so much swelling it cuts off the blood supply, meaning the tissue becomes more damaged and inflamed due to to the lack of blood. A vicious circle. His leg looked completely normal.

It took me a very long time to try and convince him that Dr google was not in an ideal position to assess his leg, and if he did have acute compartment syndrome his leg would have destroyed itself by now. After 30 minutes of my time he left to try some paracetamol and rest.

Benign Paroxysmal Positional Vertigo

2015-01-26T22:36:00.000+00:00

Hi,

Had a rewarding experience today in GP world - a lady came in complaining of severe dizziness for the last month or so, and I managed to diagnose and treat the condition in about 10 minutes, leaving a very satisfied and surprised patient!

When patients complain of dizziness, it is important to find out what they mean by this - importantly separating out the symptoms of vertigo (feeling like the world is whirling around, like you have just stepped off of a fast merry-go-round)

Not all fun and games

She had these vertigo symptoms when looking up to do her mascara, and when turning over in bed. This is very suggestive of a disease called Benign Paroxysmal Positional Vertigo (BPPV) where there are little crystals in your ears which keep the fluid moving after you stop your head from turning, making it feel as though you are still moving/spinning.

A simple test for this is known as the Dix-Hallpike test, and simple involves having them sit on a couch looking at 45 degrees to one side, then rapidly lying them down - this makes them feel very dizzy and makes their eyes spin in circles (rotational nystagmus). A potential risk of this manoeuvre is you make the patient feel so poorly that they then vomit on you. fortunately this did not happen here!

Because this condition is due to the crystals in the inner ear, it can easily be cured by putting the patients head through a series of different positions (known as Eply manoeuvre). This basically shakes the crystals out of the inner ear and cures the problem.

This is exactly what I did - aided in part by good ol' Wikipedia on my phone by the bedside as I had never done these moves before. It worked wonderfully, these problems which had ruined this patients life for a month were gone after a few minutes of turning around and about. She was able to walk out of the practice cured and happy, very grateful for what I had done. It made my day, being able to cure someone with your bare hands (and the not-insignificant power of Wikipedia!)

Time out

2015-01-24T22:03:00.000+00:00

Hi,

I know it has been a very long time since my last post - (months!) but I have been mulling over this GMC situation I mentioned in my last post. I have decided that instead of posting long detailed posts as I have been before I will just post a little story of bit of information that I have been thinking about without background, adding to the anonymous person-and-situation-changing that happens already. I don't want to stop writing things down...

That being said, finding time for writing things down is tough! When I last posted I had just finished my F1 and was starting a rotation in A&E as an F2. I now just completed the 4 month rotation in A&E and am working as a GP now for the next four months.

A&E was amazing. The breadth of different conditions, learning different skills, and all the crazy reasons for people coming in was great. I looked forward to going into work each day, and perversely, while all the nights and weekends were a bit rubbish, having time off during the week was really nice. Lots of very sick people, exciting trauma situations, people with odd things in odd places and so on. I am now applying for A&E speciality training and have my interview soon. Hoping that this goes well!

Despite all of the 4 hour target pressure and the news about A&E being swamped (it is) I think I am finding my new rotation on GP more stressful. In A&E there is great banter with the other staff, always people to ask to help out, and the sense you are all in it together. In GP I am stuck in my own room, trying to see people every 15 minutes who usually have little wrong with them, but occasionally can be very complex. Trying to pick the complex ill patients from the rest is difficult without any investigations, and trying to manage time to see each patient in about 10 mins (leaving time to do paperwork, referrals, etc) is very difficult. The simple patients who have colds and want antibiotics should be able to be seen in 3-4 minutes, but usually take 10-20 due to all the arguing over the fact that they want drugs. They patient who is suicidal and depressed cannot be condensed down to 10 minutes, and makes everything run late. At least in A&E if you need to spend more time with a sick patient or difficult case you can, in GP it is a real struggle. As you get more experienced working as a GP I am sure this gets easier, but is still a crazy idea.

I think most of the difficulties with being a GP isn't around making complex diagnoses or performing complicated procedures (though there is a lot of scope for these), but it is mainly around communication with patients. I thought I was good at communicating - had dozens of lectures on it at medical school and 'practice' it plenty with friends/at the pub/all the time but this can be a real struggle!

Either way - I am now applying for A&E, hoping that this crisis in UK hospitals gets better (some good comments on the problems places like this) and now on GP which is much less relaxing than I hoped!

The good, the bad and the ugly

2014-08-15T02:33:00.003+01:00

Hi,

I am sorry for not posting in some time. There are a number of reasons for this - first and foremost that sadly I am very busy at the moment. Another reason is that I have been reminded of the GMC guidance for doctors a few times over the last few months (the GMC monitors and regulates doctors working in the UK), and this guidance states that (and I quote) "If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name." This guidance can be found here under point 17. The GMC also makes lots of other recommendations such as not revealing any patient identifiable information (I re-iterate that I mix and match, and change patient information so none are identifiable at all).

This is obviously concerning to me as I have worked hard to be working as a doctor, and I enjoy it a lot, and don't want to lose it because I am breaching this guidance. The option of losing my anonymity as per the guidance seems to be an even worse option, as I feel this could impact on patient confidentiality. If people knew where I was working.studying then does that make it easier to identify people I may have seen?

Some thoughts for me to ponder on, while I leave you with some thoughts to ponder on. The great Junior Doctor Switcharound has been and gone, and I am now working as an FY2/SHO/TLA in a large teaching hospital. This whole period seems a little Mad Hatter's Tea Party-esque where all junior staff up and leave their jobs on a Tuesday and start work on Wednesday. You have the evening to move to a different house, and work out what the new job requires. I am sad to be leaving behind my old hospital, I felt as thought I knew most of the people who worked there and whenever it was a tough on call or night shift there would always be a nurse or two on each ward that I knew who would kindly (or not so much as you will find out!) brew me a tea/feed me cake/tell me interesting stories to keep me going! I have now moved to a much larger hospital, so I am sadly expecting it to be a little less friendly, with less of a community feel, but I am hoping to be proved wrong!

The real reason for this post, general natter aside, is to say that I think that key hospital events fall into 3 (or sometimes 4) categories. Good, bad, ugly and occasionally miraculous. I will give some examples from my last month as an FY1/HO that may make interesting reading

Good

A few weeks before this event, a lady came to our ward who we diagnosed with very advanced breast cancer. My consultant - who is a very straight talking man - advised her and her partner that if they wanted to get married now was the time, as they didn't have much time left to decide. A few weeks later she came back into the hospital getting sicker much more rapidly, but with her wedding planned for a few days time. Sadly she was far too sick and couldn't make the wedding that they had planned. I worked with the hospital chaplain and we organised a wedding in the ward for them. We turned the clinical room into a bridal room for her to prepare, and many of the other patients got involved. A wonderful experience with a bittersweet ending, as she sadly died the next day. Letting the couple share that moment of happiness didn't take any medical skills, but meant the world to them. As Robin Williams' Patch Adams said:

"You treat a disease, you win, you lose. You treat a person, I guarantee you, you'll win, no matter what the outcome."

Bad
I was talking to the lovely lady who I mentioned in my previous post with heart failure and she mentioned that she had been getting recurrent abdominal bloating and had lost a bit of weight recently. The consultant had already ordered a CT scan of her chest, and I asked him if it was worthwhile adding a CT of her abdomen to the request to look into this. He said he didn't really think it was, but I did it anyway - and now she has a diagnosis of advanced ovarian cancer. Since I explained this diagnosis to her she seems to have lost a lot of her fight and I had to leave the hospital before she was discharged, though it looked like she was getting worse. The fluid build up in her lungs had been due to the ovarian cancer. I am not sure if she will manage to leave the hospital, and in part I feel like I am deserting her moving hospitals, but I know that is silly.

Ugly
During one of my on call shifts over the weekend I had worked from 8AM to 6PM without anything to eat due to the never-ending stream of jobs, and the nurses on my normal ward took pity on me and when I arrived to do the jobs they had asked me to do, they instead took me to a side room and fed me tea and a slice of birthday cake! I was famished so I quickly devoured both, spluttering thanks (along with cake crumbs) to the nurses. After I had wolfed it all down, I asked them where the cake had come from - was it one of their birthdays?
No. It turned out that it was a cake which had been given to a 94 year old naturist on our ward who was very sick with hospital acquired pneumonia (more likely than pneumonia caught outside of hospital to be caused by unusual weird and wonderful bugs). [On a side note, this 94 year old wandered the corridors every night, naked after taking her clothes off, and pressed herself to the windows of the nursing station to look at the people inside!]

Not only had the nurses fed me this geriatric-cake, but they had actually seen her blow/slobber our her candles over a few minutes (those lungs weren't too good, due to all the pneumonia). The family had kindly given the nurses half the cake, but the nurses were not too sure how safe this cake was, so had decided to test it on me. These were not even random people I didn't know - they knew me well as I had worked on their ward for a few months. It was all meant to be a joke, but sadly this joke ended up with me eating some super-bacteria-infected-victoria-sponge. Fortunately I didn't get too sick. I felt a little man-flu-ish over the next few days but nothing worse.

A similar incident happened to me over a previous weekend on call - one of the respiratory specialist nurses I knew well from my previous rotation was doing bank work as a ward nurse, and asked me to come in and see something 'urgently' as she was worried about it. It was a very large boil on a man's back, which I dutifully (with gloves on) began to inspect it. Unfortunately after touching it, it started squeezing large amounts of pus out of it, like toothpaste. This was very unexpected, and of course I had to deal with it professionally. I got some gauze and made sure all the pus came out (once I had started I had to finish) while this nurse and the HCA sat their giggling at me. The man thought it was hilarious as well - he must have been in on it. The persecution I suffer while just trying to carry out my house officer duties like re-writing drug charts!

Miraculous
A brief mention at the end for a miraculous event. There was a lovely man on our ward who used to foster children throughout his adult life - he would have different visitors every day who would all call him uncle (calling foster parents mum and dad was discouraged as the kids already had a mum and dad) and come from all over the UK to visit him. He had a number of problems, but while he was on steroids to treat one problem, he ended up with a perforated bowel and systemic sepsis due to the contents leaking into his abdomen. I tried to get the surgeons involved, but they felt that he was far too sick for surgery and said that they couldn't operate. Without an operation to close the leak, he was almost definitely going to die. He was unconscious with a GCS of 3 when I left him on Friday. I considered writing up what would have been the medications used on the Liverpool care pathway (but now are not after it was phased out) but decided that because he was not in pain or suffering I would just write them up 'as needed' rather than as a continuous infusion, which would remove any discomfort but likely hasten the dying process. I left him on intravenous antibiotics to try and control his fevers. When I came back on Monday I was very surprised to find that not only was he still alive, but he was now awake, though still confused. Over the next couple of weeks he improved dramatically to a point where he was medically fit, though still needed rehabilitation to get him back to the independent self he was before he was admitted to the hospital. He was discharged to a smaller, rehabilitation hospital. His perforation must have sealed itself, and the antibiotics done their work on the infection. The ever-reliable wikipedia I linked above for 'perforated bowel' states that "Surgical intervention is nearly always required" - this must have been one of those few cases where luck wins out.

So, 4 categories and more stories than I could possibly write here. I have now moved to working in A&E, so more (non-patient-identifying) stories to come hopefully!

P.S - This is an amazing set of tips from another blog by halfadoc (now 100% doc) for future junior doctors which I had to link, as they are both true and hilarious!

All the small things

2014-06-12T23:45:00.002+01:00

Hi,

I have just come off of a long day's work and thought it was worth sharing an observation based on a couple of patients today.
I have noticed that it seems to be the small things that make patients happy and thankful, rather than the big things that we think matter the most in the medical profession. Take the two patients below.

The first patient is a 35 year old woman who has an aggressive, metastatic cancer. She was in under us a month ago and my consultant hinted to her long term partner that perhaps they could consider getting married due to the poor prognosis. She came back to us this week, much sicker and more poorly, sadly having planned her wedding this week, and having to miss it as she is in hospital, sick. We have been trying to get on top of the infection she has, and the cancer, to give her more time, but this is difficult. We are not sure she will be able to make it out of the hospital, and I have started trying to organise a wedding for her inside the hospital. Since this planning started, she has become a different woman; much brighter, much happier and much more healthy. All of the complex medical procedures and drugs we have been using for her haven't really made much of an impression, but this small idea has made her a different person. Every time I see her she thanks me for the idea of the wedding and the plan, but never thanks the consultant for the chemotherapy or for the complex surgical interventions that have been used.

The second patient is a lady with heart failure and fluid build up on the lungs. We have been taking all this fluid off, and she can now walk properly due to being able to breath, and her legs not being all swollen all the time. This has made a huge difference to her, but today on the ward round, and yesterday on the ward round, she just wanted to say thanks to me for talking to her and listening to her worries. She is worried about her husband, and how he is coping at home without her, she is worried about her sister and her new diagnosis of cancer, and she is worried about her own heart. On Tuesday I had a sit down and chat with her while taking some bloods for 30 minutes or so, and now every time we see her she wants to thank us for being so kind and listening. Not for all the diuretics which have sorted out her lungs, or the ultrasound which diagnosed the problem.

The problem I find with medicine is that moments like this; where you can sit down for 30 mins to talk to someone about their worries about their family; or where you can try and sort out a wedding in a hospital, are not usually possible in hospital medicine. I spend most of the time chasing my tail around with far too much to do. I like to think that, if we employed a few more people then we would all have more time to do things like this - things we all want to do.

I feel like I have had a really rewarding day because of these things, not because of the ascitic drains I put in today, or the clever diagnosis of rheumatoid lung I (might) have made, and the patients feel the same. It would be nice to have a system which let us do more of these things, but I will certainly do my best to try and do what makes a difference, clinical or not

Lord Voldemort

2014-05-30T02:02:00.000+01:00

Hi,

Firstly I would like to apologise for my last post. I realise that the title of this blog is 'Internal Optimist' and I also realise that the last post was not very optimistic at all! I had had a pretty rubbish week and it was cathartic to come online and moan about it. Thank you for your support though!

Since then times have been a bit easier - there have been some difficulties - for example the SHO post where I work has been empty because the SHO who is meant to fill it is on maternity leave, and now one of the registrars and one of the consultants from the team has left the hospital to pursue other interests. This has left our team somewhat depleted, and the workload a bit higher than normal. Despite this there are positives (as well as the fact that I am currently on nights for a week so have escaped the increased workload of the day team!) - Anyway this is in danger of becoming another mopey post like the last one, so I will just tell some stories of what I have been up to / some interesting observations.

The last few weeks have been quite emotional. There have been quite a lot of deaths on my ward, which has been quite upsetting. I think this is partially because the gastro ward I now cover has a lot of sick people on it, lots of end stage liver disease and the like, and I also think I have its been very unlucky that recently there have been lots of people who are very sick. One of the most emotional moments with all of this came the day after a patient with decompensated alcoholic liver disease died. He had been in for about a month and I had got to know him and his family very well over this time, as they visited every day. He was requiring regular ascitic drains to keep his abdomen from filling with fluid, and kept fluctuating between being relatively well and acutely sick. Finally, sadly, he died due to 'SBP' - a bacterial infection of the fluid inside his abdomen. The final time I saw him was when he had started spiking temperatures and his markers of infection in his blood were rising. I went to take blood cultures from him and start antibiotic treatment, and explained the situation to him and his wife in a friendly way. We had a few laughs, I went home and when I came back the next day he had died overnight.
The next day I had to go down to the bereavement office to fill in the death certificate. As I left the office, his family were sitting out there in a group, tearful, waiting for his possessions and the paperwork. His wife, tears streaming down her face, gave me a huge hug and an outpouring of thanks. Thanking me for being so kind, so caring and fun. "he really enjoyed the last month because of you"... It shocked me and I couldn't really think of anything to say other than 'thank you', and 'sorry for your loss', but I spent the rest of the day in a contemplative mood. Death is not something I like at all, but it is something I had been getting more used to, given all the sad things which have been happening in the ward recently. Being exposed to the relatives right afterwards was not something I was used to, and I think it bought home to me a little more that the patient isn't just an isolated person in hospital who you see. They have their entire family, friends, neighbours, children. All of who are heavily affected by the events. It sounds obvious but its not really something that was in my mind before.

To lighten the mood a little, one of our other patients (a Romanian man) came to our ward telling us that he had serious problems with his liver. The story was that he had developed a yellow tint to his skin but without any other symptoms (painless jaundice makes you worry about pancreatic cancer), and his GP had sent his blood for some tests. 2 weeks later he had called his GP, but been told that it routinely took them up to 4 weeks to get the results and report them to him. Not satisfied with this, he took a plane back to romania, got his blood taken privately in a hospital there, got the results printed, then came back to the UK and came into hospital with the results to get treated. I think it is pretty shocking that our system is less efficient than travelling to a different country (one we tend to see as much less developed than our own) to get the results and bring them back with you! Sadly, on further investigation, he did have a pancreatic tumour. Medicine seems to rarely supply happy endings!

A few interesting observations from the hospital:

There seems to be a war of wants between the nurses and doctors, and the bed managers. Bed managers come around every morning telling people to discharge more people, the calls go up that they are not safe to go home, but we need the beds. What are we meant to do? We keep people in hospital until they are safe to go home (doctor/nurse want) but then we have nowhere to put the new patients that come in via A&E (bed manager want). It seems hospitals just don't have enough beds in them. It is a shame that this seems to create opposition between the bed managers and the doctors, rather than letting them work together for an outcome they could both be happy with.

I am not sure if anyone else has noticed, but medical professionals seem to hate the word 'cancer'. We always seem to take about "Breast C.A." or "Bowel C.A" rather than saying 'cancer' or 'malignancy'. It reminds me of Harry Potter where they characters don't want to mention Lord Voldemort, instead mentioning him as "you-know-who" or "he who shall not be named". I am not sure why people say "C.A." instead of cancer (its the same number of syllables) but I agree with Dumbledore - instead of being scared of the name, taking the power from that name is an important part of the fight!

Deaths, difficult families and the worst day yet

2014-04-13T23:59:00.001+01:00

Hi,

The last week was a terrible week. Very busy and a lot of difficult conversations with families when I didn't feel I had the time to give them the attention they wanted. My new rotation is gastrointestinal medicine, and it is very busy. The last week seemed to have someone dying every day. Many of these people were people with end stage cancer or other serious conditions, but this didn't make it any easier for me at all. The last 8 months or so I have been very fortunate and only had a couple of patients die - now it is terrible.

My week started off on call, where among others I clerked in a lovely gent who was in his 60s and had the same birthday as me. He had a pneumonia (I am still pleased with myself when I get a diagnosis, even one as barn door as this - makes me feel like a 'proper' doctor rather than a glorified PA) and his oxygen saturations (the measure of the amount of oxygen your blood is holding) were about 80% instead of the normal 95-100%. Other than this, he seemed pretty well. With pneumonia it is common to use something called the CURB-65 score to estimate how severe it is, and plan your treatment. This man scored 0, but I started him on the treatment plan for 'high risk' pneumonia (normally a score of 3 or more) because of his poor oxygen levels (not included in the CURB-65 score). A CURB-65 score of 0 suggests that this patient should have a 0.6% chance of dying from the pneumonia, but sadly 2 days later he had passed away. After having a good time joking with him about sharing a birthday, I was quite upset by this - especially as it had been so unexpected. I am pleased I had started treating him with intravenous antibiotics (as high risk) rather than oral antibiotics (as you normally would for a CURB 0 patient) as otherwise I would have felt as though I hadn't treated him properly, but I still felt upset over this. 0.6% still gives you that slim chance that someone may die...

Sadly the week got worse from there, cumulating in Friday which was the worst day I have had since I started work last August. It started off like a normal busy day, our ward works with 2 consultants who take it in turns to accept all new patients, and Friday is our day, so there was quite a lot to do. Part way through the ward round (up on the 2nd from top floor of the hospital) we get a bleep from the surgical ward (ground floor) saying one of our medical outliers has some chest pain. This happens a lot (invariably nothing) so I ask for an ECG and break off from the ward round to go down and check it out, expecting to be able to go back and join in a few minutes. I arrived on the ward, to be shown an ECG with good going ST elevation.

ST elevation in an ECG from wikipedia

I was panicked - what to do? ABC! MONA?! or should I be preparing him for PCI? I started treatment and then bleeped the cardiology registrar. No answer - I bleeped the other 3. No answers, so I dragged my registrar down away from the ward round to come and help me out. Fortunately it all went well, we continued ACS treatment (so many TLAs!) and the ECG changes went away, the patient didn't need PCI today (and he is still doing well)

Sadly, because my registrar and I were pulled away from the ward round (which the consultant completed on his own, as he needed to run a clinic in the afternoon) we were not too sure about the jobs that needed to be done. The SHO is in nights, and the registrar had to go to the consultants clinic in the afternoon, leaving me to work out what needed doing.

This is when the real trouble started. One of the patient's on the wards bloods came back with a high potassium, which means that they need certain intravenous medications (like insulin). I prescribed these medications while talking on the phone to one of the F1s from the acute medical unit. They wanted to transfer a sick patient to the ward from there, but needed a medical handover to do this. He explained that this patient was for palliative treatment due to her breast cancer which had spread extensively throughout her body, and she was too sick to be transferred to a hospice. He said she was already on a syringe driver with medications such as morphine to take away any pain or suffering, and just needed some TLC on the ward. I accepted all this and said I was happy for the transfer to happen.

As I come off of the phone and hand the prescription chart to the nurse in charge of the ward, one of the other patient's relatives want to speak to me. He has end stage liver disease and is too old for a transplant, he currently has a bacterial infection in his abdomen which we are trying to treat with antibiotics, but not very successfully. It turns out that on the ward round in the morning, the consultant had been exploring the idea of going down a more palliative route with this man and his family. The thought being that the infection was only getting worse, and we couldn't give him a new liver to replace the old one that the alcohol had destroyed. It seemed that the way he had done this was leaving the family and patient (who was not well enough to process information) to think about what route they think would be best, as continuing active medical treatment would involve a central line, a nasogastric tube and more invasive treatment. Having thought about this from the morning, the family felt quite put out by this and felt that they were being asked to make a decision about whether the patient should 'live or die'. We were always taught at medical school that these sort of decisions should be made clinically, then the decision communicated to the family with their agreement - it isn't fair to leave this decision to the family, so I agreed with why they were so upset. I felt this was a decision a little too advanced for me to have to deal with, and went to pull my consultant out of his clinic to talk to the family, which he wasn't too happy with. It is decided that this patient is for full active treatment, and I need to find the 'IV team' who are the team who can insert central lines and suchlike. As it is a Friday, if I do not get these in today then we will have to wait for Monday, which means no antibiotics or fluid over the weekend, as we cannot get any venous access on this patient, which would not be good.

On getting back to the ward, a nurse told me that no-one had been able to give the treatment to the man with a high potassium, as the man had no cannula in to give intravenous drugs. It is about 5PM now and my official time to end the shift. I went to start setting up the equipment to insert a cannula and my bleep went off. I decide to answer it before putting in the cannula, as leaving it would mean they would keep bleeping me while I was inserting this cannula. It is the radiologist calling through an urgent report on one of my patient's scans. This lady has suspected bowel cancer (but not proven), and had been feeling a bit dizzy and faint so we had done a CT scan of the head. This CT scan had shown a very large mass in her brain which was squashing the brain up and starting to lead to coning within the brain (where the swelling squashes the important parts of the brain that control breathing and can lead to death). This needed urgent neurosurgical input, so I prescribed intravenous dexamethasone (a steroid to reduce the inflammation) and called the neurosurgeons to talk through what they wanted me to do. While on the phone to them, the nurse comes to tell me that they still cannot give my treatment for high potassium or the dexamethasone as no-one is trained in cannulation on the ward. I ask if they could call one of the other nurses from another ward to help out (though the neurosurgeon is not happy to be interrupted)! The neurosurgeons want an urgent MRI scan before deciding what to do.

I go to get the equipment to insert these cannulas when a very angry man storms into the nurses station and starts shouting that he needs to speak to the doctor in charge. I am the only doctor on the ward, so am asked to speak with him. He is visibly distressed and shouting about his mum; the lady with breast cancer who had been transferred to the ward a few hours ago. He is shouting things like 'why are you killing her' and 'What is this sh*thole anyway', and physically threatening staff members. I tell him I will happily talk to him at his mum's bedside, and go to look at the patient's notes to prepare myself for this conversation. By now it is about 7PM and I am left in the ward on my own. It seems that this lady with metastatic breast cancer has been known to the palliative care team for some time, and has accepted her diagnosis and the fact that she is dying. With this knowledge I go to speak to the son, at the patient's bedside. Her husband is also there. Her son is very angry, and stands with his face about an inch away from mine and shouts at me. I think about asking the nurses to get security, but decide that it might escalate the situation. It is understandable that he would be upset given the problem with his mum, and I don't want to make things worse. It seems that before the patient left the acute medical unit it was not explained to her son (who was not there) that she was dying and the decision had been made to make her comfortable, as there was nothing more we could do. In addition to this, she seemed very distressed when I was at the end of the bed - the medications she had been put on before transfer were at too low doses to alleviate all of her symptoms. I am stuck behind the curtains with this man accusing me of killing his mother, the poor lady who is visibly distressed and her husband who is just crying. The nurse pops her head around and reminds me that the two other patients are still awaiting cannulas, and they cannot give the steroid to the lady with the swollen brain, or the man with the high potassium (which gives him a risk of arrhythmias and death). I feel so out of my depth, but there is nothing I can do.

I ask the nurse who has popped in if she can give some more midazolam and morphine to this distressed lady, and continue trying to explain things to the son. He isn't having any of it, though, and has decided that I am too young to work there and he wants to speak to someone 'proper'. He wants to know which consultant made the decision for palliative care, so I tell him the name of the consultant who saw her in the acute medical unit. He storms off to talk to the consultant, and I try and explain things to her husband, but he is too busy crying.

I put in the two urgent cannulas, and call up radiology who are not interested in performing an urgent MRI as it is now far too late. I have to explain to the lady with the mass in her brain that she probably has metastatic cancer which has spread to her brain, as she keeps asking the nurses why she has been started on dexamethasone - trying my best to not rush but to take my time and explain things gently. The acute medical consultant calls me up, not happy that I sent an irate patient down to bother him when he is busy. I am too tired to protest, or care.

It is now about 9PM, 4 hours after I was meant to leave. I still have most of my jobs from the day to do. The day on call has now changed to the night on call. I call up to let them know about the sick patients on my ward, and then get on with finishing off my day jobs. It would take longer to hand them over and explain the situations behind each patient than just doing them myself.

Before I leave, I check on the patient with metastatic breast cancer to make sure she is more comfortable. She is sleeping soundly. The son had gone home hours ago. The husband is still there, and he gets up, shakes my hand and just says "Thank you so much. For everything." The look in his eyes is all apology, he is so guilty for what his son was doing and saying.

I leave for home, physically and emotionally drained, but that handshake at the end made the world of difference to my week.

Nights

2014-03-03T19:32:00.003+00:00

Hi,

Just completed a set of nights, and I am still unsure as to whether I enjoy them. The positives are that there seems to be a good team attitude of 'we are all in it together' from the other doctors and nurses during the night, and you get to see quite a few ill patients, which means trying to work out what is wrong with them and hopefully putting things right. This is a lot more active for the brain than my daily job, where the consultant does most of the thinking and decisions, while I spend time following orders and filling in paperwork. Sadly there are negatives as well: I get really tired, and then after the nights I cannot sleep properly for the next week or so as my body clock has flipped; there are very few seniors in the hospital to help support with the above decision making, so if several people get sick you are going to have to be confident in your initial management as it may be an hour or two until someone more senior can come and review the patient; there is also the flood of menial jobs from the wards which have been forgotten by day teams (like writing up regular medications) - sadly all of this cumulates in very large sentences...

While I was on call over the week, there were quite a few sick people on the wards, sadly 2 of these people died. It was difficult to try and manage multiple ill patients as it involved heading between different wards to try and manage each patient while trying to answer the random bleeps that kept coming though (such as one patient who kept having 4-8 second pauses on his heart tracing without any symptoms. Very scary!)

Parts of the ECG for the asymptomatic patient with the pauses. In the end the cardiologists put a pacemaker in, but scary stuff (for me, he didn't seem to notice) overnight!

The craziest part of the night was when I arrived on the gastroenterology ward to write up a new drug chart, as the old one had somehow been lost when transferring the patient from another ward. While sitting at the table trying to work out which drugs the day team had put the patient on during their stay, and which had been stopped (harder than it should be!) I noticed one of the patients had a defibrillator attached to them. In my experience defibs are only usually attached when someone is having some form of cardiac arrest (or you are worried that they are) so seeing a patient lying still in bed hooked up to one of these really confused (and scared) me... I jogged over to the patient, and saw they were breathing (good start) and looked asleep (to be expected as it was 5AM) so I asked the nurse why they had the defibrillator on them. Supposedly the day team had wanted cardiac monitoring for the patient, but the cardiac monitor that the ITU sent up didn't work - so they had just hooked up a defibrillator to use the tracing that it produces instead. I was confused (and a little concerned - what if someone changed the settings and accidentally shocked the patient). On the plus side, at least if the patient started getting more ill there would be no delay in initiating monitoring and treatment during resuscitation...

Like this, but the defib was manual so showed the heart tracing from between the pads

Confidentiality

2014-02-22T19:50:00.000+00:00

Hi,

Firstly I would like to apologise for taking so long to update my blog, and explain why this has been. One of my colleagues at work approached me a little after the last post and asked if I had a blog online. I asked her why she thought this (obviously not wanting to admit this as its confidential etc etc) and she mentioned finding the blog online while searching for F2 application information, finding it interesting reading a few posts and from them feeling that 'it sounded a bit like you'. On reading further she found more information about what I had been up to in my F1 life (such as laser tag) and linked it to me, she didn't recognise any patients, though, despite being on surgery with me. This worried me, as while I anonymise all patients I mention in the blog, changing and mixing facts about them, I don't really want this blog to be linked to me personally. This isn't because I say anything in it that I feel is inappropriate in the blog, but I feel that being able to link it to me makes it more likely I will censor the emotions and opinions I want to write about. A recent news article over a hospital worker who was disciplined over making inappropriate comments on twitter (anonymously) also scares me. This operating department practitioner said some pretty silly things (such as planning on using a patient's body hair to make him sideburns like Bradley Wiggins) and rude things about the executive board. I don't think I have said anything this serious, but this man was trawled through the media, and investigated by a professional body and cautioned. I don't want this to happen to me.

I have had a good think, and a chat to a some friends/family about what they think I should do. I think I will carry on posting but I will try and say a lot less, just little bits about what I have been up to and some funny stores. Hopefully by keeping things brief (and professional) I remove even more patient identifiable data, and minimise the information that people could use to identify me.

Over the last months so much has happened. Most importantly (to me) my favourite patient sadly died. This was someone who had been in the hospital for well over 100 days from when I was doing surgery. I have talked about them previously in the blog, and while on nights last week I was called to an arrest in the surgical ward. On arrival it was this patient who had arrested (completely unexpectedly) and we did all we could but couldn't restart the heart. I was really affected by this happening at 4AM, while I was trying to look after another patient on a different ward who was getting sicker and sicker (and subsequently died), and I had to go and sit down, have a little cry, and wonder if this was really the right job for me. Having had some time to reflect, this is the right job for me, but I am going have to get better at coping with things like this happening. I have been very lucky so far that not many of my patients have died, but things can only get worse...

And for some quick bullet points to get across some of the more eye-catching things that have happened since I last posted

- Homeless heroin user on the ward, complaining about the service that we could offer them. They are telling us on the ward round that 'they pay taxes too, and should get more methadone'. My consultant replies curtly 'there is no VAT on Smack' and walks off. Ballsy and it took some time trying to persuade the patient to stay in hospital afterwards, but very brave!

- On call repeated bleeps from 'outside lines' (often the consultant calling from home to make sure you are doing OK) actually turning out to be recruitment agencies trying to get me to join up. Lying through switchboard to get to medical people working then trying to sell. Not the best time guys!

- 30 year old obese man came to hospital with breathing problems, got stuck in his car in the car park and had a cardiac arrest: the paramedics had to dismantle the car to get him into the hospital. Fortunately he survived. It was thought he arrested because the getting trapped inhibited his already problematic breathing by putting pressure on his chest, leading to a respiratory arrest.

- A man I was clerking telling me he had a 'cauliflower heart'. Very confusing until I realised he meant he had had a Coronary Artery Bypass Graft (CABG or cabbage in medical slang)

- Behind curtains seeing one patient while another talks on their phone, unaware we are next door "get some of those chocolates for the doctors when you come in, they have been lovely.... No not those ones, they are too dear, get the 2 for £5 ones, then we can keep one" Then looking sheepish as we come to see them next on the ward round

- A patient telling me 'that was a really good session' after I performed a digital rectal examination on him. Needless to say I didn't go back and see him again, and left it to my colleagues instead!

My posts may take more of a vibe like the above in future (though more frequent, and less long). let me know what you think (if anyone is actually left reading this after this hiatus!