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I’m settling into my new job as the surgical F1.
The way I can tell that I’m working with surgeons, who are turning out to be unexpectedly lovely, is that sometime between medical school finals and FRCS, some of them, no matter how lovely, have clearly given themselves a common sense-ectomy. To wit, the instructions I was given on Monday on the ward round vis a vis one of the very well elective patients who was almost ready for discharge.
“Beth, this man had a heart rate of 90 when he was assessed in pre-op and he had a heart rate of 90 during theatre and he had a heart rate of 90 when he returned to the ward post-operatively and now he still has a heart rate of 90.”
“His ECG has been normal.”
“His other obs are all fine.”
“So, I got the F1 who was on the ward last week to check TFTs. If those are normal, can you refer him to medics for cardiology assessment, please?”
… Wait. What?
1. Thou shalt have a basic grasp of mathematics.
You are looking after between seven and twenty patients. Your FY1 is looking after a minimum of 96 patients. She is entirely within her rights to growl when you try to tell her that you are “very busy”.
2. Thou shalt learn how to read a EWS chart.
The score for BP is for systolic BP, not diastolic BP — a diastolic BP of 8o does not trigger an urgent clinical review, no matter how many times you try to tell me that it does. The nausea score is not part of the EWS — you cannot decide that a patient whose obs are all normal is scoring EWS 3 because they were sick three times. And if a patient has had their parameters adjusted, you need to observe the new parameters — your FY1 is unlikely to be impressed with your long-standing COPD patient’s SpO2 of 91%.
3. Thou shalt put non-urgent jobs on the non-urgent jobs list.
You do not need to page your FY1 to rewrite a Kardex.
4. Thou shalt not put urgent clinical reviews on the non-urgent jobs list.
A review of a patient with a new tachycardia does not belong on the non-urgent jobs list. A review of a patient who has dropped her systolic BP by 40 in the last hour does not belong on the non-urgent jobs list. A review of an unconscious patient with a blown pupil does not belong on the non-urgent jobs list.
5. Thou shalt not harrass.
It is a waste of your time and your FY1′s time when you page her “just to check whether you’re coming back to the ward” or “just because we haven’t seen you yet today”. She has not forgotten that she is covering your ward and she has not gone for coffee. If you have not seen your FY1 for a while, it is because the brown stuff is hitting the fan somewhere else. The only way your FY1 knows that you are paging her with a stupid question rather than a properly sick person is if she stops what she is doing and calls you back, and if you are the third person to pull your FY1 away from a properly sick person just to tell her that it’s been a few hours since she looked at her non-urgent jobs list, she will be rude to you and she will not apologise later.
6. Thou shalt learn how to use a telephone.
Do not page your FY1 and then walk away from the phone. Do not page your FY1 and then pick up the phone to make another phone call. Do not page your FY1 to the paging system.
7. Thou shalt not expect on a Saturday that which can (and should) wait until Monday.
You may be right in thinking that your patient’s high blood sugars, which have been high for a fortnight and which they are asymptomatic of, are steroid induced, but your on-call FY1 is not going to make a unilateral decision at the weekend to stop steroids that they were started on by a neurosurgeon for their brain tumour.
8. Thou shalt use SBAR.
The on-call FY1 has never met your patients before. If you ask your FY1 to review a patient, she will expect you to know why you want them to be reviewed, what their current obs were, what their obs were before that, and whether a plan has been made by their day team. If you ask your FY1 to review a patient urgently, she will expect you not to have gone on your break in the three minutes it takes her to walk up the stairs.
9. Thou shalt read.
If you ask your FY1 to prescribe analgesia/anti-emetics/fluids for your patient who is, quote, not written up for any, your FY1 will assume that you have actually checked and will be unamused when she comes to the other end of the hospital and opens up the Kardex to discover that you had not checked and that those things had been there all along.
9. Thou shalt realise that it is in your best interests that your FY1 does not keel over in the middle of the ward.
If your FY1 says at 6pm that she is leaving the ward to buy lunch and will be back in five minutes, do not block her path and ask her to “just…” unless your patient is actively trying to die. It is at this point more important for her to treat her own hypoglycaemia and acute renal failure than it is for her to treat your patient’s nicotine withdrawal.
Today, every foundation doctor in the country changes jobs.
It isn’t like Black Wednesday — we’ve all been here for eight months, at least, and are slightly less terrified than we were on the first day of our first jobs, back in August, and mostly know at least where the toilets are by now, and it’ll be another four months before the next set of newly minted doctors start work. It’s still weird, though, because no two wards ever keep blood forms or radiology requests in the same place and you keep writing down your old pager number and the consultants are all different and you don’t actually remember the first thing about gastroenterology.
It’s a curse and a blessing at the same time that, in my job, I’m almost always on the move to somewhere new. It keeps things interesting. It means that I get a lot of experience in a lot of different kinds of medicine. But just as I’ve learned all of the nurses’ names and started to sound as if I might vaguely know what I’m talking about, I’m gone.
I loved my first job.
And then not only did I change jobs but I changed from a ward-based specialty to four solid months in medical receiving, which is absolutely crazy and like no other job in the hospital. I spent the first fortnight of my new job wandering around and muttering oh-my-god-I-want-to-go-home.
A few weeks ago, I talked about feeling as if I was getting burned out on receiving. It’s a fast pace and a high turnover and a constant string of long days punctuated by the occasional day off, and unless, I suppose, you’re an acute physician by temperament, which I’m not, it’s difficult to keep that level of energy up for four months all in a row. I would like, just occasionally, to finish work before bedtime. I would far rather have done a second general medical job and had both of them punctuated by receiving weeks and receiving weekends, which is the way my SHOs and the F1s in a lot of other hospitals do. Anyway, a lot of it is because this isn’t the job that I want to do — among the best parts of medicine for me are having my ward and having my patients and getting to the end of the story, and that’s not what this has been about.
So, yes, I did get burned out on it.
But that isn’t the whole story.
Because once I conquered the oh-my-god-I-want-to-go-home feeling of once again not having a clue what I was doing, I learned a lot and I worked with some cracking people and I had fun. I learned how to make a management plan for real and how to take responsibility, and, oh, so much about the kind of doctor I want to be and also the kind of doctor I don’t want to be. I’ve been right and I’ve been wrong, and the times I was right were important but I’ve learned more from the times I was wrong. The most crucial thing I’ve learned, I think, is that there are ways to make a difference to people even in an environment like that, and that an environment like that is maybe one of the places where it’s most important to do it.
I’ve been on nights this week and I worked last night, the very last night of this rotation. Thus, why I’m at home writing about my old job instead of at work doing my new one, but it meant that I hadn’t left yet when the F1s who are about to start there came crowding into the office for their induction, all two-thirds of the way through their F1 year, just like me, and every one of them looking like Sputnik had crashed down on their heads. The best way to deal with that is to just jump into the chaos and not think too closely about the way nothing really makes any sense and trust that it will, eventually, come to make its own kind of sense, somehow.
It’s just how this year goes.
Looking like Sputnik has crashed down on my head is after all precisely the way I looked in August and again in December and precisely the way I’ll look again on Friday when I realise that I have to work with surgeons now.
The scene is the medical receiving unit, at the nurses’ station, shortly after lunchtime. I have apologised and tripped and generally made a nuisance of myself to squash past three nurses and into the corner, and I am now crouched on the floor, foraging in the bereavement drawer for paperwork.
I get nudged in the back. I ignore it. There are a lot of people crammed into a small space, feet and elbows and knees everywhere. Besides, I’m preoccupied with wondering where all the crem forms have gone.
I am poked again, harder.
And then there is a voice from far above my head…
Nurse 1: What are you doing?
Nurse 2: I’m moving this chair out of the way.
Nurse 1: Eh?
I suddenly become aware that the thing that I’m being poked with feels a lot like a shoe and I look up.
Nurse 1: That isn’t a chair! Did you try to sit on Beth?!
I’ve been watching the new series of Junior Doctors, which has been on BBC 3 for the last month and this year is set in the Royal Liverpool. It’s a very surreal thing to watch – not like during Series 1, when I was a fourth year medical student and being a proper doctor was just far enough away that this was all a bit exciting, and, besides, that was in the hospitals that I had grown up around; and not at all like Series 2, which aired right through written finals and less than five months away from graduation and, well, I never worked up the nerve to actually watch it. Series 3 shows five doctors who started working on the same day that I did, and now I have these memories that run almost in parallel to the things I’m watching on TV. I find myself having flashbacks to things like wanting to vomit the whole way to work on my first day and trying not to giggle the first time I had to tell someone I was a doctor.
And so when Emily talked a few weeks ago about the death of one of her patients, I remembered being that doctor and that the first time I agreed it was time to stop was the single most heartbreaking thing I’ve done in the last six months.
It was a weekend, I think. Perhaps. The days all merge together in the end until one day you look up and it’s February. I had never attended an arrest before. Not really. I had been to never-mind-patient-just-fainted arrests and patient-drank-coffee-while-having-five-second-runs-of-asystole arrests and oops-thought-that-was-the-light-switch emergency buzzers. I had one day when the arrest pager went off five times and none of them were an arrest. I had done all of the adrenaline-racing pager-going-off-on-the-loo pounding-up-three-flights-of-stairs-in-dress-shoes… and then I had turned around and walked back down the stairs and back to my day job. It was a joyous state of affairs, but one that could hardly last forever.
On that day, I was drinking coffee and writing a discharge letter when my pager started in with rapid sequence of bleeps that mean “on your marks” and the fuzzy hiss of static that means “get set”. And, on that day, when I arrived on the ward with the rest of the team, I didn’t arrive to never-mind-patient-just-fainted or to oops-thought-that-was-the-light-switch. I arrived in Beirut.
I remember wondering what the other patients in the bay must have been thinking.
The noise hit me like a brick wall, muted through the pounding of my own blood in my ears.
For a split second, the only thought I had was, “Shit, this is for real.”
And then I waded in.
In the chaos around about, there were people putting up fluids and trying to get a better venflon in and looking for somewhere to take a blood gas and getting out the emergency drug box and leafing through medical notes. I think I ended up taking control of the airway.
He was a patient who I hadn’t known before. I don’t know why he was in hospital or what had happened to take him to that point. I think he was pre-op, or post-op, maybe, but I don’t know for what and I might even have just assumed that because of the ward he was on. I don’t know his name. I could describe him, perfectly, what his face was like in that moment, but he didn’t look like that before I met him and I don’t think he would have wanted people to remember him the way I do.
They asked if I could take over CPR. I nodded. It isn’t like the training. It’s a million miles away from the air conditioned room and the mannekin and Nellie The Elephant. My stethoscope and ID lanyard were on the floor, thrown there when they had started to get in the way. I thought, with my lungs burning (“watch it, Beth, there’s a sharp coming out near your leg”) and heart racing (“third round of adrenaline in”) and muscles screaming (“has the gas come back yet?”) and sweat starting to roll down my neck (“still in asystole, continue CPR”), that if this was it for him, this would be a horrible way to die, so please, I thought, please don’t, wake up and just stop being dead, stop it now. It doesn’t get more personal than this. “We aren’t letting you die,” I heard someone mutter. “You aren’t dying, not today. Don’t you dare.”
It felt as if we were there for hours and at the same time for no time at all.
And then the noise stops. At the beginning of an arrest, there are bloods to be taken and access to be got and drugs to be given and things to be found out and problems to be fixed. Later, all of the things that can be done have been and all of the things that can be fixed are being and the only noises left are the quiet occasional hiss of the ventilator bag deflating and the odd grunt from the person doing CPR.
The consultant took a breath in. “I think going on now won’t make any difference,” he said. “I think we’ve done everything that we can. Does everyone agree that we should stop? Does anyone object?”
We had done everything that we could. We had.
“Thank you,” he said.
Afterwards, I had picked up my stethoscope and ID from where they had landed and I had walked back down the stairs and was going back to my department to somehow get on with the rest of the day. The living don’t go away just because the dead are dead. On the way, the colleague I was walking with offered me a hug that I fell into, crying like I had managed not to upstairs, and I have seen some awful things in the six months that I’ve been doing this job and in the two years before that, but being in that room, with that man and on that day and at that time, that is the thing that I will never ever forget.
I spent most of yesterday sitting on my sofa, trying to convince myself to stay awake.
Just before my first set of nights, in December, I asked Twitter for advice on how best to switch from day shift body clock to night shift body clock. I had three nights in medical receiving, in the middle of a six week or so period when I had been working a lot. There had been a lot of on calls, a lot of long days, a long time since my last bit of annual leave, and, just a few days before I was due to go on to nights, the bed crisis to end all bed crises, with a fourteen hour ward round and a consultant who asked out loud in the middle of it whether we would be seeing patients in the car park before the day was over. Thus, on the day before my first night shift, I was very pleased to shuffle off back to bed after lunch and I got a decent sleep in before heading into work that evening. Afterwards, switching back to day shift body clock was even easier. Possibly because I only had twenty three and a half hours between the end of my night shift and the start of my day shift, and I had Midnight Mass to force me to wake up for a bit in the middle.
But the consensus from everyone I’ve talked to has been that when they aren’t immediately followed by a middle-of-the-night liturgical celebration, I am better advised post-nights to stay awake until what might be considered a reasonable(ish) bedtime. A little like the rule about setting watches to destination local time when boarding flights. After all, night shifts are basically just a very peculiar sort of jetlag. And as I imagine that the Church as a whole would grumble at the idea of inventing liturgical celebrations for no better reason than to ease my days-to-nights-and-back-again transitions — although I will note that by happy coincidence, Easter this year will be very much doing exactly that — I was stuck this time with resisting the lure of my duvet through sheer force of will.
I’ve quite enjoyed my nights this week. I spent half of one of them in the emergency department, on account of a complete lack of beds anywhere else in the hospital, but, for the most part, things have been manageable rather than stupid. It’s been a good team, fuelled mostly by Haribos and potato scone sandwiches and giggling. I’ve seen some things that I haven’t before, felt just a little bit smug about a far-too-early-in-the-morning hunch that was proven right, and even got some bits of ePortfolio done during one of the quieter spells. The end of a working night, falling asleep in handover with rumpled scrubs and undone hair, feels like an accomplishment in a different way than getting to the end of a working day. It feels like an enormous achievement to clear ED in time to batter down the canteen doors for a Team Nightshift breakfast and a relief to finally get rid of the arrest page — a particular highlight of my week was the look on the face of the medical student who almost found herself with the SHO arrest page in her hands, such was the eagerness of my SHO to get to his bed.
I could do without being back on nights next weekend, mind, but I’ve given up on figuring out my rota.
In the end, yesterday, I made it to quarter past four in the afternoon before I conked out on my sofa in front of Lewis. And but for a brief period of consciousness to shuffle bedwards, I was dead to the world until after eight this morning. Mission accomplished.
The last few weeks have not been a particularly auspicious time to be a member of the British medical profession.
This month, it has been suggested that I regularly practice euthanasia. I’ve been accused of manslaughter and of murder. I’ve been told that I’m killing off elderly patients in order to meet my bed managers’ targets and that I will choose to end the life of people who I think are worthless.
Well, not me. Everyone.
There are a handful of journalists, who admittedly mostly work for the Daily Mail and are therefore not really journalists, who have declared war on the Liverpool Care Pathway and, mostly by association but also a little bit by calling us arrogant and high-handed, have also declared war on all doctors everywhere.
The Liverpool Care Pathway For The Dying Patient, or the LCP, is an integrated set of guidelines, developed based on the hospice model, that is used to improve the quality of life in the final few days and hours of a patient’s life. It is used in patients in whom a diagnosis of dying has been made. If used correctly, it involves the stopping of most treatments and the starting of palliative medications where those are appropriate; the stopping of investigations and routine checks of heart rate, blood pressure, and so on; decisions being made about the appropriateness of fluid or nutrition based on whether those things will make a patient more comfortable rather than using them to artificially prolong their life; carrying out regular checks to ensure that the pathway is still appropriate and that no changes need to be made to it; and making sure that social and spiritual support, where wanted, has been made available to both the patient and their family. If a patient rallies and no longer appears to be dying – and the fact that this is a thing, both because doctors are sometimes wrong anad because sometimes miracles happen, seems to have become a huge source of scandal rather than the cause for celebration that I would hope it might be — the diagnosis of dying is reversed and the LCP is stopped.
It has been in use in the NHS for over a decade.
And, suddenly, kind of from out of nowhere, there are articles and the op-eds and the commenters who, honestly, to read them, you would think that Hitler was a fluffy bunny rabbit compared with British doctors.
I don’t take death nearly as lightly as they seem to think I do, and nor does anyone I work with. I am never less than saddened when one of my patients is given a terminal diagnosis and it is never anything less than a solemn thing when I go to pronounce someone dead or to see someone in the mortuary. The first time I was asked to start a patient on the LCP and the first time I was asked to pronounce a patient dead were on the same day, for the same patient, on my first weekend on call, when I had been a doctor for two weeks. I hadn’t eaten anything or stopped moving for ten hours, but I sat down in the doctors’ office on that ward and I cried buckets.
There is a body of opinion that says that it would support the use of the Liverpool Care Pathway in hospice medicine, which, they say, is where it was originally designed to be used, but think that it is inappropriate to use it in hospitals. But to do that would be to miss the whole point of the LCP — designed in a hospice, yes, in a place where end-of-life care is done very well and where they never actually needed the LCP, but with the express intention of taking those principles of good end-of-life care and putting them into a format that could be easily used in hospitals, where end-of-life are has often been done terribly. It is disingenuous to suggest that a pathway that enables the good management of dying patients is useful in hospices, where 16% of cancer patients died in 2003; but that it is inappropriate for use in a hospital, where 55% of cancer patients died in 2003. I guarantee that those numbers would be even more skewed for non-cancer patients.
Professor Peter Millard, emeritus professor of geriatrics at the University of London and therefore a man who really ought to have known better, is quoted in the British Medical Journal this week as saying, “In practice, it’s time consuming on the people doing it, and it doesn’t seem that once a person is on it, they can come off it. It is not flexible enough to be changed or sophisticated enough to take into account that person’s particular circumstances.”
The LCP can be used well or it can be used badly. If it’s used well, it is a wonderful thing and highly flexible and, sorry, Professor Millard, but we do take patients off it. If it’s used badly, it’s a failure of education and training and communication and occasionally circumstance – and the answer to that isn’t to get rid of the LCP itself. And, yes, starting someone on the LCP is time consuming, but, you know, taking care of a dying person is time consuming and, if we’re doing it right, so it damn well should be.
I find the implication that I want my patients to die to be deeply deeply offensive.
I want my patients to live. I want them to go home to their children and their grandchildren, whole and healthy, and to live long enough to forget that they ever knew a young doctor with glasses and a Geordie accent. It happens, sometimes, I hope. The days when I can hand over a discharge letter with a handshake and a smile and a teasing admonishment that I don’t want to see them again, those are good days.
But part of doing what I do is learning to accept that, sometimes, people die, and that, sometimes, there is absolutely nothing that can be done to change that, and that the only thing that can be done is to make sure that, when it happens, it’s with as much comfort and dignity as possible. There are good deaths and there are bad deaths. If you’ve seen a bad death, you won’t ever forget the difference. And the days when I know that a dying patient has slipped away painlessly and peacefully and with their family around them, those, through the tears that we don’t ever let fall in public, those are good days too.
An improbable proportion of my week has been taken up this week with trying to get the results of a single blood test.
The majority of investigations that are done in my hospital are processed internally. A small number are sent to one of the teaching hospitals in Scotland, where there are bigger labs and the facilities to run investigations that are needed less often. And as I learned when I came into work on Monday, there are a very small number of investigations that are run by no labs in Scotland. I have therefore spent a lot of my time this week on the phone to a biochemistry lab in Abroad. (The south of England. Abroad.) Too much time, probably, as I’m on first name terms now with an English biochemist who, on Wednesday, promised that my result would be back by the end of the week.
So, late this afternoon, when my consultant began to swear that, if he had to tell his patient that she would have to wait for her results until Monday, he would be taking me into the room with him so that I could be used as a human shield, I got on the phone again.
A word of warning to any budding medics: an atrocious amount of your life as a junior doctor will be spent on the phone.
I squinted at the phone number that looked like I had scribbled it upside down with my left hand and a drying-up biro while simultaneously doing six other things. I probably had. I was on call yesterday and spent most of the evening writing phone numbers on my forearm.
“Hello?” said a man’s voice.
You might think that this would have been your first clue. But one of the local hospital switchboards routinely answers the phone with, “Hello,” which is why it took me five full minutes last week to work out that my switchboard had put me through to the wrong city.
“Hi!” I said. (I was in a ridiculously good mood.) “Is this the University Hospital of Englandshire Biochemistry Lab?”
There was a long pause.
No,” said the voice. “This is Mr Smith.”
That probably should have been my first clue. It was Friday afternoon and I’ve had a busy week. “Hello,” I said. “Are you based in the University Hospital of Englandshire?”
“No,” said Mr Smith. “I’m based in my house.”
I’m going to tell you a secret.
O&G has a lot less to do with babies than everyone thinks it does.
I grant that this is partly because obstetrics only accounts for half of the specialty, while the rest of it concerns itself with prolapse and smears and weird bleeding and, I suppose, the prevention of babies. It is, however, also partly because although obstetricians are terribly interested in potential babies and in safely getting those potential babies to the outside world, that’s pretty much where that interest ends. Children? Well, those are someone else’s department.
But this is a five week rotation and I felt I ought at some point during that time to see a ‘normal’ delivery. Not only because I’m supposed to. Not only because I think it would be fairly appalling to graduate from medical school without having a least made an attempt. Rather, because when the inevitable day comes that I’m flying home from somewhere warm and beach-esque and they ask if there’s a doctor on board, nobody will be too appalled when I admit that I cannot perform a coronary bypass at three thousand feet (or at all), but they will be if I’m forced to confess that I have never seen a baby delivered before and have no idea where to begin.
It was with that thought that I went off to labour ward and found myself a friendly midwife and an understanding set of parents-to-be who weren’t remotely fazed by the prospect of having a medical student sit in the corner for the next several hours. The mum had already been in labour for the better part of a day when I got there, hadn’t slept or eaten in more hours than I care to imagine, wasn’t using pain relief, and announced cheerfully between mouthfuls of Entonox that she had long since given up on the idea of being embarrassed about anything pregnancy related. For the next six hours, she chatted to me about all manner of things and occasionally paused to have a contraction before picking up the conversation right where she had left it. And once she reached the stage of what they call active labour, she gritted her teeth and got right down to it and pushed that baby on out with barely a whimper.
It’s not to say that it didn’t look like hard work. I was vaguely horrified by the whole thing, especially when the doctor brought out the episiotomy scissors, and I’m beginning to feel that evolution should surely by now have reached a point where storks really do bring them. I have never been through the childbirthing process myself and have no particular wish to do so, but I suspect that I wouldn’t handle it with an ounce of the grace and stoicism that this woman did.
And suddenly there was a baby and a new mum and dad and even I got a bit teary.
Incidentally, I learned at this point that if the inevitable day does come when I’m on the plane, the only thing I’ll really have to do is catch.
O&G isn’t as much about babies as everyone thinks it is, but it is a little bit about babies and the part that is is a wonderfully happy thing in a way that so much of medicine tends to not be. And although I think that most of the things that I do and see as a medical student are a privilege, there is something of an extra special privilege in being there at the very start of a new life and I was very proud to have been there for this one.
Welcome to Planet Earth, little one.
I’m halfway through my psych rotation and thoroughly enjoying it, far more than I’d expected I would.
My rotations worked out in such a way that my specialties have been sort of smooshed together at the end of fifth year. And because I also chose to do general medical type things for both of my electives, this means I’ve spent the better part of the last year and a half in general medicine, which is the subject of my delighted and unconditional love; and general surgery, with whom my relationship is best described as one of mutual and mostly happy tolerance. It’s strange, then, this close to The End, to find myself so very much out of what has become my comfort zone.
In my first week, I was coming home every night slightly bug-eyed at some of the things that I’d heard. I have one particular patient who is very pleasant and very happy to chat to me and has excellent insight into his condition, but is also quite floridly psychotic – which simply means, more or less, that he knows that he’s psychotic. Now, the cognitive dissonance that such a concept creates in me is headache-inducing, at best, so one can only imagine how difficult it must be for him. He’s unusual. My patients more commonly run the spectrum from the ones with fairly stable chronic disease who are being seen by outpatient psychiatrists to the ones who have no insight at all and scream at us on ward rounds and kick me out of the room.
It’s a truly fascinating speciality.
I think my fascination with it may say more about me as a nosy person than it does about it as a subject.