Medicine "oop North"

[M Clayton]

I'm hoping to make today "three in a row day" - if I post something about nobody reading my blog I might just get more messages professing undying love for me

In all seriousness, it was really nice to get some messages that were triggered by the junk that I write here. It certainly beats the other type of message I get (the "please sir, tell that boy to stop doing what he's doing" messages) and, maybe it's just me but, how exciting is seeing that little pop up which tells you you've got a message!? Ok, it is just me then apparently

There's nothing exciting to talk about today really. I could tell you about my day at work (yes, paid work during the holidays, again) but it's very much the same affair as every other time I've talked about it. It does have occasional moments of soap opera like silliness with divorces and cat fights among the reception staff to tide me over but, overall, it's a dead loss. If I were to give you a true reflection of my working day, we'd have entries that look a little like this;

Arrive @ 08:30. Drink water from cooler. Say hello and Goooooooooood Mooooooooooooorning to scary Dutch GP (he likes that greeting in just that way).

8:40. Fight computer in vain attempt to log on before hell freezes over.

8:50 Succeed. Open Spider Solitaire and play for the next hour while briefly doing some work.

Type (this is work btw, in case you hadn't guessed)

Type

Sip water

Type

Type

Skip this song on the MP3 player - it's cack and I don't know why it's there.

Type

Type

Open Hotmail and see that there are no new mails.

Type

Type

Type

Scribble on the handily located free notepad. Realise that my bladder is full and needs emptying to prevent leekage related nastiness.

Return having scorched hands whilst washing them.

Open Hotmail and see that there are still no new mails. Compose desperate e-mail to everyone on my contact list in the hope that someone (anyone!) will reply.

Type

Lunch.

Ah, let's skip the afternoon and go home now eh?

So, that's that. You don't want that and I certainly don't want to be reminded of just how crappy work actually is, so we'll have no more of that in future.

I was going to talk about the fun and games I had getting my Aussie visa, but if I talk about that now, I'll have nothing to say tomorrow. So, until then, adieu.

[M Clayton]

It has been brought to my attention that I have, in fact, passed the 300 entries mark. Now, this isn't really that great an acheivement when you consider that others have far more than that and that my blog largely consists of posts of the "tired, will post later" or "sorry for not posting, too busy now" ilk. However, I'm never one to turn down praise and, as such, I thank you for your congratulations

At work today, I got myself worked up about an issue that I'd not considered before. I'm in the middle of doing some research (yes, I was that incensed!) and I might come back and post about it at a later date. For now, assume that work today was like any other.


I promised to tell you about my Australian visa so, in the interest of filling some white space, I will. I had a real nightmare trying to work out which visa would actually be suitable for my elective - the standard tourist visa has some clause about not performing medical or surgical procedures, the working holiday visa likewise. My supervisor couldn't tell me which she thought was useful and the embassy suggested that I pay them a lot of money to get an occupational trainee visa, for which I'd need the university of Sydney to sponsor me. They said no. In short, I had no idea which visa to get and felt as though it would be easier to stay in the UK rather than expend any more energy.

Then Joy came to my rescue and told me exactly which visa to get (short stay business if you're interested) and which additional evidence I should send to make sure they said yes. Easy peasy. All I had to organise was a blood test for HIV, a chest X-Ray to demonstrate my lack of active/past TB and a letter from my uni proving my medical student status.

Have you ever tried to get an HIV test? Everyone wants to counsel you about the consequences of your decision and then, if you have it done at your GPs, they need to order a special form and box to transport your blood in. In the end, I got the form, bottle (which is actually nothing more sexy than a yellow biochem bottle!) and special transport box (aka, small cardboard tube with a biohazard sticker) from the hospital myself and had one of the SHOs in A&E take the blood for me.

Lo and behold - a negative result. So much for the counselling requirement eh? I will admit to being a little bit relieved when the result came back - even though I'm certain I've not partaken in high risk behaviour, there's always the worry that it would come back positive. One hurdle successfully leapt.

To be continued...

[M Clayton]

Visa stuff. That's where we were yesterday, right?

In addition to the blood tests, I need a chest X-ray. I had intended to con the radiology department into providing me with the relevent films but the Australian visa people informed me that only an x-ray reported by one of a number of specific radiologists would be good enough. Would it surprise you to hear that these radiologists all seem to conveniently work for private hospitals? I think I mentioned the trip to the Nuffield Hospital in Jesmond at some point in the past, but that half hour visit cost me £66 plus my dignity (I challenge anyone to look good with their hands on their hips whilst taking a big breath...)

So that was the second hurdle over and done with.

The final step should have been the one that caused me the least trouble. After all, I've been a medical student now for 4 years - it shouldn't be that hard to prove it, surely? My initial enquiries were met with a flat "no" from the medical school office but my continued moaning finally made them see sense - 4 weeks later!

With all of the gubbins in place, the form filled out as required and enough money in the bank to cover the cost, it was finally time to send the whole package to London and pray for the best.

2 days after I'd paid 12 quid to send the form (with an envelope for them to return my passport to me), I received my visa! 2 days! All that worrying for a 2 day wait. It would appear that they'll let anyone into Australia these days...

[M Clayton]

Written last night - posted today due to technical difficulties.
----

As these things go, today could be considered to have been one with "room for improvement".

It started out fairly well, with the successful completion of "Operation Sensible Haircut" before lunch. I am now in possession of much less hair (and, as a result, cranial insulation) and my head actually does look smaller. For £7, I expected bells and whistles, but all I got "post trim" was a paper tissue to wipe the hair off my face with. Great!

Pretty soon after I had returned, showered and had lunch, it was time to head off to the football for the regular duty at the KC (that place in the picture)




This is where things started to go a bit awry.

Regular readers out there will be familiar with the fact that the vast majority of public duties that I've covered with St. John pass off without much in the way of major incident. In fact, I don't bother telling you about most of the duties I cover because there'd be nothing to say. On occasion, I get a bad feeling about how things are going to progress but, happily, I can usually put this down to a simple case of cystitis (I'm kidding!). Very rarely, my bad feeling turns out to be well founded and, as you might have guessed, today was one such day.

It started pretty soon after the match kicked off with the incident team (a fancy name for what consists of a St. John technician and me) being called to attend an urgent case in the South Stand. Knowing that it's a fair walk from the top of the West Stand to the South Stand concourse, we set off at a quick walk in order not to arrive out of breath. A second priority call indicated that the casualty was an unconscious child and, at that moment, all thoughts of walking were swiftly dumped in favour of what can only be considered to be a mad dash down 4 flights of concrete stairs and along hundreds of meters of stadium concourse. On arrival, the child was about as far from being unconscious as it’s possible to be and not be running around. Brief history from the kid and his family indicated that his problems lay with terrible ear pain and that he’d felt sick and sat down. At no point had he lost consciousness but he did concede that he might have “closed his eyes”. Seems like a case of overreaction from the people that called us in, wouldn’t you say? In deference to the fact that the A3 patient report form requires lots of info, I did bother to take the child to the first aid post for a quick check over before advising that he go home to bed and see his GP.

Once clear, we traipsed back up to the very top of the stadium and settled back down for a quiet match.

Not so.

Approximately 5 minutes after we'd reported being back at our holding point, we were dispatched to the same First Aid post that we'd just left. Astonishingly, we arrived to find a TENYAS ambulance crew already on scene and getting ready to move the patient to their vehicle for transport to hospital. They must have been there before we received the call, so quite why we were sent was a mystery.

The rest of the game moved along with much the same level of activity. Following our 3rd wasted trip back to the top of the West Stand, we redeployed ourselves to the First Aid Post in the away stand in order to avoid having to go up and down like yo-yos. Miraculously, the calls stopped coming.

Signing off the duty at ten past five, I thought I'd dodged a bullet once again. Yes, my legs ached a little bit but I didn't really have to exercise much in the way of clinical skills and judgement. I'm sure I can be forgiven for putting on my "off duty" head on and thinking about what I was going to have for tea. Certainly, the person I was grabbing a lift with was firmly in that mindset. She spent the 5 minutes it took to walk across the car park to her car telling me about the steak and chips she was planning to have that night and had just begun to tell me about a recent operation when one of our colleagues arrived at the side of the car lookinf very flustered. We'd travelled about 300 meters from our parking space and were stuck in traffic so it was no great trouble to get out and find out what was wrong.

Something was very wrong.

No more than 50 metres ahead of us, a crowd of people were gathered around a prone body and a yellow jacketted St. John member. This was not good. I can't remember my exact thoughts, but they went along the lines of

"SHIT!"

Having suddenly been dragged from my happy little world of steak, chips and recent operations, there was a real need to calm down. Clearly, I'm of no use to anyone if I can't remember what to do or get myself run over en route.

Arriving on scene, first impressions were less than encouraging. An oldish looking man lay against some advertising hoardings in a pool of, what I assume was, his urine and vomit. A member of St. John I recognise by site but don't really know was performing mouth to mouth ventilation and a number of bystanders were making frantic 999 calls. This is the first time I've had a pre-hospital resus situation without having advance equipment available. Between us, we've got two response bags and some pocket masks. No defib, no oxygen, no bag & mask. Things could be worse, but they could be so much better. If this had happened in the stadium, we'd have it all. Back to basics time.

I move on to assessing pulse. The first guy on scene is coping well with airway management, so I leave him to it. My colleagues have now dumped the car and arrived to offer assistance. Without being told, they both automatically get to work; one of them deals with the crowd and the other starts emptying the contents of a response bag looking for something, anything, we can use to make this job easier.

No pulse. He's already cold and his face has gone that dusky purple colour that I recognise all too well from the bodies in anatomy. We're losing this and we've not even started yet. It's funny what you notice when the adrenaline is flowing and the tunnel vision sets in - the moment I go to cut open his jumper, I tune out of the background comotion and focus on the task at hand. I don't notice that I'm kneeling in vomit and won't until much later. All I can think is how his jumper doesn't look like the sort of thing an old man would wear - it's too "young". I start chest compressions and I know I'm going too fast - I have to work really hard to calm myself down and make this work. I'm not wearing gloves but I don't really care. I can care about that later.

The man groans and starts thrashing at me to stop. In my heart, I probably know that this isn't really anything to be pleased with but for a brief moment I think we've done it. It soons stops, but not before I've done the stupid thing of asking for him to be put into the recovery position. I hope that this might clear the crap out of his airway but without suction, it's not very likely. His thrashing stops and I realise that it wasn't a sign of recovery at all - his "breathing" wasn't the sort that fills your lungs with life giving oxygen. It was the utterly futile efforts of a dying brain - agonal gasps.

I swap places with airway management guy. I know I've got a set of OP airways in my bag and ask the third member (aka flustered guy) to hand me them. The first one is too small and I waste too much time sizing it when I know that it's not good enough. I've gotten out a pocket mask now - mouth to vomit streaked mouth doesn't fill me with joy. If I'm honest, I'm a little bit disgusted by it all. Success. I've gotten the correct sized airway in and that's the tongue dealt with. It's not really success though - I can see the thick slime that's probably already gone deeply into his airways but you have to try, right?

Where's the ambulance?! It's been forever and I can see this man's gone way past the point of no return - we're paying lip service to it now.

I can here the sirens and I allow myself the luxury of a look around while airway management guy gets on with chest compressions. Traffic is backed up for miles and I can't see the ambulance getting through it very fast. My colleagues are switched on though and start taking advantage of the fact that people will respond to orders given by anyone in a fluorescent jacket to move the cars out of the way.

I'm on autopilot now, past thinking about what I'm doing. Breathe, pause, repeat. I could do this all day and not have any impact on the condition of the man in front of me. His pupils are fixed. He's not moved now for 5 minutes. His face is purple and his torso is pale. I feel certain that I can hear his chest click each time there's a compression but this might be just my imagination.

Finally, the ambulance crew are here and we're brushed aside in favour of their bag and mask, their oxygen and their trolley.

"What happened? Who is he?"

I realise I can't answer either with any confidence. All I can tell them is what I've seen and what we've been doing. Luckily, someone else can give them the full story.

"He's 73, has Alzheimer's. He just fell over"

I'm handed the BVM while they load him onto the trolley.

"Put this on the vehicle, will you"

And then that's it. They've gone, blue lights flashing, horns and siren blaring.

Were it not for the debris of an unsuccessful resus, the pool of urine and the silent crowd, you'd have no idea that someone had died there.

As we clear away the mess - the used mask goes in a yellow bag - and fill in the form, we're asked what'll happen to the man (I still don't know his name). We can only reply that he's gone to the best place possible and that they'll do what they can. I know he's dead but, perhaps oddly, I'm not upset. I know we all did our best.

Shit happens eh?

[M Clayton]

Just a quickie since I'm not in the most favourable place for typing long entries.

I've come home (aka Stockton - not my real home per se, but my spiritual one definitely) for my final 6 week SSC.

Rather foolishly, I've signed myself up for anaesthetics and critical care - neither of which I'm that clued up on. "Never mind", I told myself, "They'll teach you what you need to know". And they will... The unfortunate caveat being that they expect me to have some knowledge of physiology and anatomy. Both of these subjects have, essentially, been dumped from my long term memory in favour of amusing quotes from Family Guy, Scrubs and The Simpsons.

I spent today in the day surgery unit being taught how to use LMAs and the anaesthetic machine. Despite being a total retard when it came to the physiology and pharmacology (oh yes, pharmacology too - dumped in favour of a working knowledge of hospital corners), the consultant trusted me enough to "let me" cannulate all the patients whilst he had, variously, a cup of coffee, a sit down and a wander. Surprisingly, since I've not done any cannulation since my A&E placement (and I failed more than I managed there :S), I managed to get them all in first time. Score one for me!

I also did my first LMA insertion today - yes, it's the easiest of the airway adjuncts, but it still felt good to get it done!

Righto my lovelies - I must dash. There's a hour walk back to the hospital from here and I might just get eaten by wolves if I leave it too late. If you don't hear from me again, avenge my death!

[M Clayton]

Not eaten by wolves - obviously, since I'm here posting and not being digested in the belly of a wolf. Unless it was a very slow process and, somehow, a wi fi signal could make it through the wolf skin and subcutaneous tissue to reach me inside... no, I'm being silly now.

Anaesthetics is scary. They keep doing silly things like trusting me to insert LMAs and not screw it up or manually ventilate a patient whilst practising my anaesthetist grip. I know that they're there to step in should I screw up, but it doesn't make it any less frightening!

So far this week, I've spent time in orthopaedic and general theatre and helped with some spinal blocks and a lot of generals. Tomorrow, I'm in maternity but we've no c-sections booked so far so it could be a quiet day....

In leiu of the fact that I can't actually be arsed to write anything really, here are some lovely photos of North Tees Hospital and my ever so delightful room;



The hospital by night (from my room) - twinkly



Less prettiful during the day, no?



Base camp, as it were.

There, you insatiable beasts, be satisfied until next time

[M Clayton]

What did I say about blog updates being crap when on placement? At least I didn’t lie to you though, eh?

I’ve just finished my second week of anaesthetics and critical care and I’m beginning to feel really confident in my abilities. Somewhat surprisingly, I even feel as though I’ve got a good grasp of the pharmacology and physiology involved! Now, if I can just dredge up that second year neuro-anatomy I might actually make it as an anaesthetist!

Since I last wrote, I’ve spent a lot of time in theatre (damn, I look good in scrubs ) or, more correctly, in the anaesthetic rooms of the operating theatres. A typical day involves rolling up at 8:45, getting changed and making sure the recovery nurses know who I am. I usually pick a random theatre list and get involved in inducing the patient. The anaesthetists are usually really keen to teach, so I get told the same thing lots of times (I’m not complaining, it’s a good way to learn!) and I'm almost at the point where I can confidently explain each of the steps in safe induction.

I cannulate pretty much every patient that has this misfortune to come across me (or I try at least!) and I'm working on my intubation skills. So far, I've gotten the whole pre-oxygenation (including the anaesthetist's grip - ooh, fancy) off pat and I'm almost happy to wield the laryngoscope. The next step would be to combine it all with the actual tube insertion but I need a patient that doesn't have fragile teeth before I attempt that!

What else have I done?

Well, I've spent some more time in Intensive Care. It still scares the hell out of me! There are way too many tubes and cables that I could trip over and kill the patient - I'm that clumsy that I probably will do that at some stage :S

Gah, I must dash, I have a bus to catch and I don't fancy walking home.

For now, adieu.

[M Clayton]

How crap are bank holiday weekends?

Not only do we have the generalised shitness of a Sunday to contend with, there's another one to deal with straight after! Obviously, when I'm a wage slave, I'll come to cherish these days but now, whilst I'm a scummy student living at the hospital, they're just something to be endured.

On another note entirely, today I did my first laryngeal intubation on a real person! Despite the fact that the patient was ASA1 with a Mallampati score of 1, I was still incredibly nervous. It's all very well slotting the tube between the cords when the anaesthetist has hold of the laryngoscope, but it's another matter entirely when you're the one trying to keep the flappy wet tongue out of the way without smashing the top teeth or removing the patient's head.

It always amazes me just how much we build up "the firsts" in our head - my first catheterisation was a disaster but I managed to get urine to flow and the patient survived the experience; first breast examination (they're just oversized sweat glands!) was a slow, shaky affair but I identified the lump; first PR was almost uncomfortable for me as it was for the patient; my first cannula tissued! But we learn by our mistakes and we get better (usually).

Here's to more firsts!

[M Clayton]

I'm currently enjoying the comforts of home - the double bed, television, broadband internet access without restriction, the decent food and free washing facilities. Oh, there's the whole family thing too...

I've come down here since I thought it was probably time to remind everyone at home that I still exist. There's also the minor issue that I've almost run out of jam. Following a simply joyous train journey home on a crowded and overheated train, I suddenly got very excited. I remembered that I had not one, not two, but three (yes, three!) parcels waiting for me on my arrival. I love getting post at the best of times (who doesn't?), but parcels are even better. Specifically, I was expecting a new pocket mask to replace the one that was binned after my failed resus a couple of weeks ago, a new response bag to fill with assorted crap and, the piece de resistance, some Technic pieces. Childish? Yes. But I need these pieces in order to complete a couple of models which I can then flog for much cash on ebay - clever, no?

My pocket mask and the bag had arrived safely but there was no sign of the Lego. This major disappointment was tempered by the fact that the bag is pretty awesome, if not a tad large...

Oh christ, my life is so dull that I'm talking about a bag. Somebody rescue me!

In the world of medicine, anaesthetics and critical care continues. I've got some sessions organised for the next couple of weeks that should be a bit different - pain management at some point next week and then some cardiothoracics in Middlesbrough in the near future.

Aren't our lilac scrubs lovely?

[M Clayton]

It's amazing what's available at your local library these days - the one just 5 minutes from my room has free internet access that is, oh, a hundred times more useful than that on offer at the hospital. For a start, it actually allows access to sites other than those on the .nhs.uk domain!

This week has gone so quickly, probably due in no small part to the fact that I've been so busy. At various points, I've spent a 14 hour shift on take, played examiner in a mock OSCE, helped at the pre-assessment clinic, participated in the pain ward rounds, joined in with a couple of failed resus attempts and induced a few patients under supervision.

The week started with a fairly bad day on Monday. It's been no secret that I've avoided spending time on ITU (for reasons that I won't go over again) but I bit the bullet on Monday and vowed to spend the day there and actually get involved. The SHO on duty was great and I almost started to enjoy myself. I learnt a fair bit and made myself useful.

At lunchtime, a lady came down from one of the surgical wards with a probably sepsis. The outreach people had decided that she was a candidate for a higher level of intervention than could be acheived on the ward. She was your typical "sweet old lady" and had been originally admitted on the Friday with a fractured wrist - a simple thing that had been successfully plated in theatre. I helped to make her comfortable and disappeared for half an hour in order to fill myself with junk food.

On my return, she was still there and we were waiting on a CT Scan slot since her chest x-ray had demonstrated no obvious infection, but a lot of bizarre looking plerual plaques. She'd been placed on Bipap since her oxygen demand had steadily increased and we discussed the possibility of elective intubation and ventilation. Her relatives thought this a good idea and, when asked, so did she.

The SHO and Staff grade prepared the intubation gear whilst I attempted to reassure the lady that everything was going to be fine.

And then, without warning, she stopped breathing and her output crashed. Obviously, the doctors abandonded all ideas of a controlled elective intubation and embarked on the futile process of resuscitation. My role in this high energy affair? I timed the 3 minute blocks of CPR and handed them saline flushes - useful eh?

Needless to say, she didn't make it.