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Life on the wards

February 14, 2014

A long long time ago, when I used to work on hospital wards, nurses were assigned to one particular ward and the doctors would be covering a number of different wards. So obviously the nurses would spend more time with each individual patient than we did and would get to know them better.

In those days nurses did nursing. The caring, the chatting, the feeding, bathing and hand holding. As well as the routine observations or ‘obs’ as they were known, that they filled in on the chart at the end of the bed. To be honest the latter were the least reliable bits. Pulse and temperature they usually seemed to manage OK, BP a bit hit and miss and hardly ever was respiratory rate recorded correctly – they just seemed to take a guess. Fluids in and out could be fairly random, but unless there was a concern over the patient’s kidneys as long as they were peeing we were happy. And for the vast majority of patients it was the human care that they were getting from the nurses that was by far the most important. Obviously in the wards where patients were very sick, then the observations took on a greater importance and were done with more diligence. But still the nurses did the caring. The gentle rinsing out of dry mouths with swabs, helping people to the toilet, painting nails and washing hair if they had time or the hairdresser wasn’t available, changing dressings, changing sheets, plumping pillows.

And we of course would swan in, white coats flapping, following the Consultant on his ward round (and they were nearly all ‘his’ in those days), trying to anticipate the questions and furiously writing down the notes and instructions being barked at us. Sister would push the trolley round and hand out the notes of the relevant patient. Each Consultant had their own preferences, which Sister knew all too well. One would want to be handed the patient notes, another would want the Registrar to have them. We’d view the XRays by holding them up to the windows, or move to the light boxes if we wanted to see real detail. In these situations Sister was far more senior than we were and could silence you with a flare of the eyebrow if she thought you were going to annoy her Consultant. She prided herself on looking after his every whim and making sure everything was ship shape.

Curtains around the bed would sometimes cause a few stifled giggles  (and a  raised eyebrow from Sister) when they would appear to have a life of their own and trap people in them. Or when they would simply peel off the rail completely when you pulled them. But the best comedy moment of ward rounds I have been on was when the Consultant, a fairly bumbling, untidy kind of guy, somehow  got the zip of his trousers caught in the handle of the notes trolley. When Sister set off for the next bed he was suddenly yanked  at such speed that when she stopped as soon as she realised what was happening, he still travelled forward so that his head ended up in the files and his feet shot out from under him and he accidentally kicked a junior doctor in the nuts. It was like something from a Carry On film; Sister mortified at what she’d done, the Consultant with bright red marks on his face where the metal bits of the files had dug in to him and his trousers still caught up in the trolley, one SHO (junior doctor)  bent over nursing his groin, and me and a nurse desperately trying not to laugh.

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The first hospital job I did was as a House Surgeon. They are called F1s nowadays, but way back then we were House Surgeons. And much of my job involved looking after the patients who had been booked to have their operations. They would arrive for their surgery which would be booked for the following day and I would have to ‘clerk them in’. This is the systematic questioning and examining of a patient to find out what the problems are, check they are fit to have the surgery and do any of the work up required beforehand. Like bloods, put up drips, write X-rays, order enemas.

And most importantly mark the side of the body to be operated on. You may think this is a joke, but it’s not. I had a thick black permanent marker that I would use to draw an arrow pointing to the Left knee, the Right breast or to circle the numerous varicose veins that needed stripping out. Because it is obviously vital to operate on the correct side, but once a patient is asleep they can no longer confirm which side it is and sometimes notes can be poorly written and it can be surprisingly hard to decipher an L from an R. It is also true to say that for things like hernias, they may not be apparent when the patient is lying down, so it is impossible to tell which side it might be even if you examined him under anaesthetic.

Which brings me to one of the most eddifying moments of my career. I was clerking in a guy for a routine inguinal (groin) hernia operation and needed to confirm it was there and mark it up with my big black pen.

an essential piece of kit for young surgeons

an essential piece of kit for young surgeons

He was probably about 35 and otherwise fit and well. I asked him to stand up and drop his pants so that I could examine the hernia. I knelt in front of him as he pulled down his boxers. His erect penis actually hit me on the nose as it flicked past in its bid for freedom. Funnily enough this scenario hadn’t been covered during my five years of medical training. But I did what came naturally. I pushed it to one side with my left hand and asked him to cough whilst I palpated (felt) his left groin. “Ah yes Mr X, I can definitely feel it,” I said, “We’ll soon get rid of that for you.”

He couldn’t tell whether I was talking about the hernia or making him an offer.

The bits I didn’t like

September 23, 2013

The only bits of medicine I didn’t like, and in fact was quite squeamish about, was eyes. There were things I didn’t enjoy as much as others, like filing, but eyes did my head in. There was a girl at school who could put her finger under her eyelid and basically wipe her eyeball with her finger. Used to make me feel physically sick.  And as a doctor it’s pretty tricky to just say “Yeuk, no don’t show me that stye/conjunctivitis/contact lens!” so I had to brace myself and swallow hard when I did anything involving eyes. Funnily enough I rather enjoyed incising and draining Meibomian cysts which are little cysts in the eyelid and you have a special circular little clamp to use once you have flicked the eyelid inside out. Sounds gross but actually rather fun.  But that’s about the only time I haven’t minded eyes.

The worst time was when I was covering Accident and Emergency and two men came in having been involved in a stabbing. The guy I was resuscitating had been stabbed in the chest,the neck and the face. The knife in the chest had pierced his ventricle – the pumping chamber of the heart. The neck one had missed the major artery but looked like it had pierced the top of the lung. The one in the face was through the cheek bone and up through the bottom of his left eye. His eye was pushed forward out of its socket and resting on his cheek.

As the anaesthetist my job was to secure his airway so that air could come in and out. Basically to keep him alive whilst the rest of trauma team worked on him. He had arrested and had no signs of life so I needed to put a tube down in to his trachea (windpipe) so I could help him breathe and some lines in to give him fluids and drugs. Someone else was on his chest doing compressions whilst trying not to squirt all the blood out of the hole in his chest and heart itself.

The cardiac surgeons arrived. We are still in casualty but they decide they need to open him up and sew up the hole in his heart.  This meant getting all the sterile drapes on and making sure the field they were going to operate in was clear of any of my unsterile equipment. No tubes or bits and bobs in the way that they might accidentally touch once they had scrubbed up.

So I had to wrap his head in a sterile green drape to keep all my tubes and stuff  well clear of the surgical area as all my equipment is not sterile. But obviously I still have to be able to access them all and check he is still breathing OK and still unconscious. Wouldn’t want him to wake up and start coughing or pulling at his tubes.

Thus I have a green drape about a metre square and I lift his head up to shuffle the drape underneath. I then take the corners furthest away from me (I am standing behind his head) and pull them up and across his face, trying to ensure I capture all the tubing. (It’s a bit like putting a towel turban on after you’ve washed your hair except I’m wrapping his face in it too). And as i bring my hand up my finger catches his eyeball resting on his cheek. I am nearly physically sick as it blobs around. I have to clip the drape with forceps to hold it in place and I am terrified I will accidentally puncture the offending eyeball but I don’t.

It’s fairly crammed in the resus room in A and E but it’s all we can do and the surgeons have split his sternum (breast bone) open and have rib spreaders in place to hold the rib cage apart whilst they sew up the ventricle. They have managed to restart his heart and they put in a chest drain to reinflate the lung that has been punctured. It’s all going on and I am keeping him alive whilst they build him back together. I’ve had to be very mindful of this eye that is now hidden under the green drapes as it is not uncommon to rest ones hands on top of them, or a piece of equipment if it were light and obviously I can’t do that as I might damage it.

And soon the cardiac surgeons leave – all flying surgical gowns and blood stained boots. And I am left with this poor guy. And his eye. It is still there staring at me from under the drape that I have now loosened but not revealed the offending globe.

We are waiting for the ophthalmic consult. The eye guys have been called but obviously couldn’t do anything whilst the cardio-thoracics are ongoing. So I wait for them. They have been called from the specialist eye hospital Moorfields which is not far away in the City.  I am dreading the eye surgeons wanting to take him to theatre and then I will have to  anaesthetise him for that and sit through the whole gruesome procedure. And eyes are so close the head where I sit, I can’t get away with not looking.

And then the door opens and two guys sweep in. In shades and black crombie coats. As cool as fuck. Seriously it was like Men In Black but 20 years before it. I removed the drape. They took one look and said “He’ll have to come back with us.” What a result. The surgery was too complex for them to do at our hospital, They wanted to take him back to the highly specialised theatre in Moorfields.

“So how did it happen?” asked one of them. “It was an argument about a parking space outside a curry house.” I said. We all looked around the room at the aftermath of a senseless altercation over something as trivial as a parking space. He was lucky to be alive and may well have lost the sight in one eye. The other guy had been whisked away to theatre with an abdominal stab wound. At various points there had probably been in excess of seven or eight people working on each victim, numerous pieces of equipment, drugs, and blood being used, It will have cost the NHS thousands and thousands. All for a sodding parking space.

I loved working in accident and emergency, or casualty as we called it. The terms are interchangeable but A and E is probably more modern. You really have no idea what is going to roll in. Sometimes literally as drink is a major player. Of course when I was working in them Casualties were often very busy, but we didn’t seem to be troubled by the shit minor stuff that comes in nowadays. Stuff that should be sorted out by a wash and a plaster, or perhaps a visit to a chemist shop. Or a visit to the GP on Monday. I mean there were time wasters, but nowhere near the level there are today. People seem to have lost the ability to sort themselves out and will call out an ambulance because they have a splinter in their thumb.

But I digress. The first time I was attached to Casualty was as a student, and I blogged here about the Hoover Dustette incident and here about the fireworks. But there were plenty of other stories. It really is a place to see all of life and we did. Sometimes in eye-watering ways.

And so it was that I was asked to see a young woman who had “Got something stuck”. I think we all know where this is going. And sure enough behind the curtain was a fairly dishevelled looking girl of about 19. Looking a bit embarrassed but more worried than anything else. I asked her what the problem seemed to be and she told me she’d got a Coca Cola bottle stuck up inside her. And sure enough, when she lay down I could clearly see the bottom of one of those nice shaped glass Coca Cola bottles between her legs. “How did it happen?” I asked, waiting for the “I was walking nude around the house and tripped over and it just went up there,” usual guff  But no. She was unperturbed to tell me she’d been masturbating frantically with the Coke bottle and suddenly she’d been unable to pull it out altogether. She’d no idea why not. She’d been pulling and pulling but it just wouldn’t come. (no pun intended).

I examined her more closely and could see that her vaginal wall had been sucked inside the coke bottle and was now swollen and unable to come back out of the top of the bottle. It was well and truly plugged in. I thought I’d better call the Gynae Reg to come and see her. This was their department after all. But of course in the mean time I was discussing her with other colleagues on the floor. I mean, these kind of cases brighten the day and raise a smile. So often we are dealing with tragedy and loss it is fun when something like this comes in. And during the conversations someone came up with the obvious solution which I hadn’t thought of. The frantic up and down, in and out motion had created a vaccuum and sucked the vaginal wall inside the bottle so all that was needed was to break the vaccuum and it would release the pressure. Brilliant.

So now we had to work out how to break the bottle without injuring her further. The colleague who’d thought of the answer came over and we thought about wrapping the bottle and hammering it but there wasn’t actually much bottle protruding so it was pretty impossible to get enough leeway to try to smash it without also risking crunching her pelvis instead. In the end we got an orthopaedic drill and drilled a hole in the bottom of the bottle and hey presto the vaginal wall was gradually and gently released and although a bit sore and swollen, she was able to go home even before the Gynae Reg had made it down to see her.

She was in and out in no time.

Breaking bad news is never easy. And comes in many guises. It’s not just about death or diagnosing a fatal disease. I gradually realised that many things qualify as ‘bad news’ to others which to me seemed relatively minor. As a student  I hadn’t understood the likely impact of my words or the preconceived ideas patients would have which meant they would interpret my breezy announcement about their condition in a way I did not predict. I would say “Mr Jones it looks like you have a condition called diverticulitis which has been causing this bleeding from your bottom” and I would expect him to be as relieved as me that it wasn’t cancer. But sometimes Mr Jones would appear to be as devastated as if I had told him he had a month to live. Because of course I stupidly didn’t realise he would have no idea what a diagnosis of diverticulitis would actually mean.  Because I hadn’t told him.

So I quickly learnt that what seemed to work for me was to be explicit upfront about the diagnosis NOT being cancer. It surprised me how many patients default to imagining they do have cancer or a serious fatal illness whatever their symptoms. Not everyone obviously, but lots of people. So I would always ask people what they thought it might be so I could be explicit and clear in my reassurance if we were able to exclude that particular problem.  It made it easier for me too as it somehow gave it a platform of being not the worst news even if it wasn’t good news. A perspective of relativity perhaps.
We had classes on giving people terminal diagnoses. What to tell them. How to tell them. How to listen. How to ask. How to remember the patient when all the family are insisting on a particular course of action.  It would often be more stressful battling with the family to treat their loved one as an intelligent adult than talking to the patient themselves. They often seemed to insist that their parent or partner would not be able to take it if they were told their diagnosis. But I had no right to withhold that information if the patient was of sound mind. And I found that patients do tend to give you pretty clear signs how much they want to know if you ask them.

As a student I had been with doctors when they were delivering bad news to patients, but there comes a time when you are the one to have to do it, not be the sympathetic bystander. Unlike nowadays, we did not have roleplays to practice our technique and responses but if I am honest I am not sure how useful roleplays are unless they use real patients who have been through it. Actors, no matter how good, are not real patients and come with their own  ideas of how they would react which is not necessarily the same as seeing it in real life.

But anyway, I’d seen it in real life before I did my first. In fact, unlike the usual medical adage of see one, do one, teach one I had seen it a few times before I was left to do it myself. I had really enjoyed my stint on the Oncology ward as I blogged here, and had seen an inspirational Consultant talk to his patients about death and dying. The best possible training. Except that this wasn’t really the same scenario…

I think it only fell to me this particular time because it was at the weekend and an emergency so the more senior doctor who had been with me trying to save the patient’s life had been called away to another patient. And the living take priority. So I was left to tell the parents and boyfriend of a seventeen year old girl that we had been unable to save her from the anaphylactic reaction she had had. Because they needed to know. They had a right to know. We couldn’t let them just wait until my more senior colleague was finished. That could have been hours. They would already have been waiting for over an hour wondering how she was doing since she’d been brought in semi-conscious. And so with pounding heart I went to find them in a small side room in Casualty.

A nurse came with me and we walked in to the room. They all instinctively stood up and looked at me expectantly.  And then the boyfriend started crying when he looked at my face. It was so hard. I had been the one who had taken the history from him to find out what had happened as by the time she arrived she was losing consciousness so couldn’t speak. Her parents didn’t arrive until later. So I already had a relationship with him. And I expect he saw it in my eyes that it was the worst news possible.

I don’t remember where the nurse was, but we all sat down. I drew my chair up so close my knees were touching the mother’s. And then I told them. I tried not to use euphemisms and said that we had done everything we could but she had died. I remember thinking I shouldn’t say things like “She’s gone” in case they might think I meant she’d gone to another hospital or just out of the building. And the father appeared stoic and supported his wife who looked shell shocked. I asked them if they had any questions and did my best to answer them. But it is often too early to have questions when you have been hit by the ten ton truck of sudden death. So in fact there were few, mostly about what she would or wouldn’t have been aware of. And whether she would have been in pain.

And they were very gracious and grateful and thanked me for all our efforts. And I felt terrible. And their niceness made me well up even more. I was trying to stay professional but I could feel the tears. The throat closing in. I wanted to leave before I crumbled completely but felt I couldn’t just get up and go abruptly. We sat and I held the mother’s hands. “I’m really sorry,” I said as I got up. The father shook my hand. The boyfriend was still as a statue looking at the floor. I touched his shoulder as I left the room. The nurse stayed to talk to them about what happens next.

And I really was sorry. This wasn’t just a trite saying. Sorry for their loss of course, But the overwhelming feeling was guilt that we had failed. Sorry we hadn’t been able to save her. And I went over and over it in my mind. Could we have done something differently? Had I done something wrong?  We are trained to save lives and make things better and it is hard to come to terms with failure, even if you have done everything possible. It was awful.

They do say relatives often remember this kind of conversation with incredible accuracy and replay it in their minds. I hope to fuck that I didn’t make things any worse for them than it already was by the way I handled it. But I’ll never know.

When people talk about stress in their work I am minded to shout that they’ve got no fucking idea what work related stress is. But I don’t of course.

Being duped

July 10, 2013

I continually get messages on Linkedin asking me if I am a doctor and if I’d like to be listed in The Leading Physicians of the World. “Are you a Doctor? – Apply to appear in the 2013-2014 Leading Physicians of the World, It’s Free”. I thought it would be a pile of shite and I think I’m right.
For God’s sake. What doctor worth their salt wants some crappy wall plaque to give them credibility? I investigated what you need to do to become a “Leading Physician of the World” and all I need to do is apply. There’s no independent review by peers, and as long as I can tick the boxes that I have qualified and done my postgraduate training, then I will be awarded the distinction of being one of the Leading Physicians of the World and can be included in the website ‘TopDocs.com’……… yeah, right. It all sounds like a shabby shabby scam to me to dupe patients in to thinking they can get themselves an expert in the field by going on the websites and finding someone listed.
I could be wrong of course, but it  doesn’t look like this listing means they are actually one of the top docs in their field – it only verifies that they are qualified in it. I’ll bet they have Michael Jackson’s doctor listed as an expert. Shipman would be on there if he’d applied. It pisses me off because it lulls people in to a false sense of security and could put unjustified questionmarks in their minds about doctors who are not listed on these sites.
If you are going to call yourselves ‘Leading Physicians of the World’ or ‘TopDocs’ then there should be an independent scrutiny panel to assess practice, research output and a clear protocol of what attributes have been assessed. Not a monkey-led checkboxing exercise.

What’s your problem?

May 17, 2013

The different way people approach things is fascinating.  I am a problem solver. Not as in mathematical puzzles so much as in I need to find answers for problems. It is what I do. It is how I function in my entire life. Everything becomes a problem to solve. ‘Problem’ in this context is not negative. It is more of a question and answer approach. I have to be able to define the problem and then solve it.

It may be my medical training. I’m not sure if I was like it any way or if that hammered it in to me. Find out what the problem is then sort it out. Nobody comes to see a doctor unless there’s a problem, so it was all day every day. I didn’t have to invent problems to solve, they just rocked up. In Casualty (OK, A and E nowadays), in clinic, in wards, in operating theatres, in the anaesthetic room, the recovery room, intensive care…. everywhere. And one of the great joys is that it’s a new problem every time. They may be very similar to ones before, but everyone is an individual and there may be special nuances to watch out for, particular hurdles to overcome.

It is how I approach everything, not just doctoring,  which is why I find it difficult doing tea and sympathy in my non-professional life. My automatic response to a friend or relative feeling under the weather/in pain/moaning  is to try to determine the cause and suggest solutions such as  ibuprofen and/or paracetamol, or go and see a film, or organise a night out. Depending whether the problem is medical or emotional.

And it is sometimes met with a curt and exasperated response that I am completely unsympathetic, unfeeling and uncaring. Which I feel is unjust of course! As I do care and my care is manifest in trying to solve the problem. But that’s not what they want,  they just want sympathy.  It took years for it to occur to me that someone might NOT want their problem solved. Or at least not at that moment, or not by be.  Because if I have a problem I do everything I can to sort it out, and I want it sorted NOW. And if anyone has a decent suggestion I’ll take it if it still isn’t sorted by my own devices.

In contrast,  some people just want acknowledgement. Not a solution.  “Ooh, yes that’s nasty” or “Oh dear you poor thing” , without the additional “Have you taken anything for it?” or, “That sounds muscular – have you tried this stretch? ” or “Well I know a good lawyer.”

I can’t get my head round it. It is a complete enathema to me.  Surely no one wants problems so if something is a problem you want to get rid of it? Or is it that it isn’t really a problem, you are just upgrading a minor irritation in to something bigger so you can have a whinge? But I know that isn’t true as sometimes the issue they want acknowledging and comfort for really is massive, and doesn’t have an easy answer. I try to keep it zipped but so often rather than sympathy I hear myself offering possible solutions to a small part of the problem and I know I haven’t helped at all. If anything, made them feel worse – as if they haven’t tried to solve it or as if it is their fault the problem is with them in the first place. Which of course would be the last thing I’d want to do, but I do struggle to keep my gob shut.
At work there are people who moan about their job. A specific task. A particular person. A given project. Or just everything in general. They exude a feeling of powerlessness, that this is simply the way of the world and a cross they must bear. Hello!!! Wake up and do something about it if it is that bad. Don’t just suck the energy out of everyone else with your negativity. Work out what the actual problem is and then try to solve it. For many it will be crystal clear the problem is in their power to solve. By not spending half the fucking day moaning about the amount of work they have to get through and actually focussing some time on the task in hand and getting stuff done. Taking decisions and acting on them rather than putting them off or revisiting them time and again after a decision has been taken. But that isn’t what they want to hear. They just want a sympathetic ear and a little mental stroke. I nearly have a stroke myself when they start up…
So if I am ever in your company and I  tell you I’ve got a problem don’t just say “Yes, dear” –  I want you to help me get it fucking sorted.

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