Medicine "oop North"

[M Clayton]

Day two.

Time management has significantly improved, due in no small part to arrival of SHO (F2/FTSTA/ST1/Whatever) on the firm. Proper entourage on the ward round this morning - consultant, staff grade, reg x 2, SHO, me and elective student. Good times.

It's been another busy day but we're slowly getting the number of patients down - we're not killing them you understand; we make them better and they go home. That's what doctors do these days.

We've a young chap who was involved in a car accident a little while ago and he's in a bit of mess really. Tomorrow, the boss is going to take him to theatre and cut out half of his liver and a smashed up kidney. He's going to give me trouble this weekend, I can feel it in my water....

[M Clayton]

It’s been a character building few days – as the surgical house officer on call over the weekend, I’ve had to deal with acute emergencies (what do you mean it’s a medical problem, I’m a surgeon!), the mundane day to day tasks of the ward (If I’d have been asked to write up another discharge summary today, I might well have killed) and great big steaming piles of attitude from everyone (patients, nurses, senior colleagues...) but, and this is the important thing, I’ve survived and I’m still smiling.
More on the weekend later but first, there’s the small matter of a couple of days towards the end of the week still to cover.

Friday was another relatively busy day. The SHO was pretty awesome though and with us both putting in a lot of effort, we had all of the planned jobs over and done with just after lunch. That left me the opportunity to get online and put myself through some ridiculous online learning module in basic child protection. Apparently, as employees of the trust, everyone from cleaners to consultants has to have a valid “Child Protection Level 1” certificate and the only way to get it is to put yourself through the 20 minute module on the intranet. Such gems as “Not only girls are sexually abused” and “Even well respected people such as doctors and lawyers can be perpetrators of abuse” demonstrated that the standard required in the 30 question quiz at the end would not be high. It didn’t disappoint and, after a mind numbing 20 minutes and 2 pence (for the printing), I was the proud owner of a certificate proclaiming my basic knowledge of all things child protection. I felt almost as good as finals results day... almost, but not quite. On my way to dump said certificate with medical staffing and whilst I was trying to work out what I’d say to them when I asked for my tuppence back I was bleeped by the admissions unit. They were pretty persistent and in my search for a free phone (York’s weird in that there are no corridor phones at all) the blasted thing chimed 6 or 7 times. Clearly something important, no? Why then, did they express surprise when I phoned the ward from reception?! “Oh, The Boss’ house officer!? What do you want?” It took them 5 minutes to find out that a patient was being admitted direct from clinic and that I was needed to write up analgesia and fluids. Amateurs.

The poor guy admitted from clinic was not in a good way. He’s in his mid 40s and has already suffered the trauma of having the majority of his gullet and stomach removed by The Boss this summer. He’d had a month of freedom from disease and now he’d bounced back having eaten and drunk nothing for a week with the resultant dehydration and weight loss nearly having killed him. It was left to me to try and ensure that his death, for it is a certainty, is as comfortable and dignified as possible. I’ve never prescribed MST for a real patient before and 10mg seems like an awful lot to be giving someone who is opiate naive but everyone assures me that it’ll be fine – in fact, it might not even be enough. “Better write him up for some Oramorph as breakthrough”. Shit.

The Boss arrived to conduct the afternoon ward round as I was struggling to get IV access – every time I failed, I wanted to stop. This guy had had a shit enough day already and me sticking needles into him was not making it any more bearable. I gave in at attempt number 4 and had the SHO give it a go. He gave in at attempt number 2. I didn’t feel so bad at that point and I almost forgave myself when it took The Boss a further 3 goes to get half a serum sample of blood (what’s that? 3mls ish?”) and the most tenuous cannula imaginable. Suddenly, it was half 5 and I’d not done my weekend tasks. Gah. Another half hour of rushed blood ordering was followed by a naff handover to the night F1 (sorry Kelly!).

And then I went home.

But not my old, crap flat. Oh no. I had a spanking new, free, flat to move into. And my god, what a difference! From the ridiculous to the sublime. I no longer have a room; I have a suite. There’s my bedroom, a corridor and then a living room which is actually bigger than my room at home. All mine! I share a kitchen and bathroom with Raj but the suite is mine. It’s awesome Bootham Park Court – all is forgiven. I take back all the nasty things that I might or might not have said.

The move did me the world of good and I got a great night’s sleep before the entertainment of yesterday and today.
I don’t know what it’s like elsewhere, but at York the F1 on call is responsible for covering all the surgical wards and the acute surgical admissions. Nightmare! It’s been an immensely busy two days as a result, but I’m still smiling and I feel pretty good for having gotten through unscathed. We started each day with a quick ward round (about 90 patients in 90 minutes, not bad going!) after which I made a list of the important jobs. Note to all potential and current F1s – preliminary discharges are not urgent jobs and should be done before you bugger off home for the weekend! It’s not fun trying to fill the bloody thing in when you have no idea who the patient is. The rest of the day was spent trying to get the urgent jobs done while fielding a thousand and one bleeps from the wards who all believed that their job was the most worthy of my immediate attention.

In truth, the vast majority of the bleeps were for stuff that really could wait – “Mr Smith’s IV fluids run out in half an hour, will you write up some more now?” (sure thing, when I come to the ward in ten minutes like I’ve already told you twice), “Mrs Jones is probably going home on Tuesday, will you do her TTO?” (Will I bollocks! – her own team can do it tomorrow) but there were a couple that were genuinely important. Funnily, those are the jobs that are recounted with absolute calm over the phone “Oh, Mrs Y has dropped her sats and her pulse is 120. We did an ECG twenty minutes ago and wonder if you could come and review it when you’re free?” – Mrs Y has flipped into fast AF for no good reason and urgently needs to be cardioverted by someone who knows a lot more than me.

Overall though, it was a pretty good weekend. Busy enough not to be bored but not totally flat out so that I had to come home and cry. Next stop, a week of acute admissions!

[M Clayton]

I wrote this last Thursday but due to a cock up, it didn't get posted.

Day what, probably six, of acute surgical admissions. It’s been the busiest day this week by far and almost equalled Sunday in terms of work volume. At one point, there were 8 unique admissions on the go and if I hadn’t had a medical student helping me with the clerking, there’s absolutely no way on earth that I’d have gotten them seen before The Boss arrived from theatre for the post take round. As it was, we ended up having one patient who’d waited 2 hours and was seen by the consultant during the rounds:

The Boss: “So, who is this?”

Me (shuffling papers): “Erm, this is Mr Y. A GP admission with abdominal pain”

The Boss: “Ok, and what have you found so far? Blood results?”

Me (increasingly uncomfortable): “Sorry sir, this is the first time I’ve laid eyes on Mr Y”

The Boss (Mildly irritated): “Hmm. Ok then”

That isolated case aside; I think we did pretty well to keep on top of the admissions, especially when you consider that there was a lot of other stuff to chase from the morning rounds. I still haven’t managed to make time for lunch during an admissions day yet, but ho hum no sense worrying about it now. I’ll just eat bigger breakfasts in future.

So yes, they’ve given me medical students to look after. Well, they’re not really mine but since they’re attached to The Boss and he’s busy entertaining work experience kids, they get dumped on me. The poor dears I’ve tried making my job interesting for them but, to be honest, there are only so many times that they can see me degrade myself before the radiologists (“Please, please, please can I have this CT scan today?”) before it gets dull. The biggest problem is the fact that they’re not allowed to do anything without supervision – they’ve been taught to cannulate (Yesterday?! And they’re final year students!) but they don’t have the experience to get on with it alone. The number of times that they try tends to ruin the easy veins so I’ve taken to just getting access myself in one go. Chalk that up to one job that I can’t delegate then... What they can do, and very well indeed, is take a history. It’s a shame it takes them nearly an hour (again, final years?!) but I suppose that thoroughness is a good trait. I realise that I sound like I’m belittling them but it’s very hard indeed not to compare them with where we are at last year. I’d sort of assumed that every medical school did the basic clinical skills early in the course but apparently they don’t. One of the other F1s recounted how her friend got through the 5 years of her course and didn’t do a single Venflon... crazy stuff.

I feel it’s time for a rant now. Bleeps. They’ve given me that magic box of tricks so that I can be found anytime, anywhere. Fair enough I suppose; I’m employed to look after a group of patients and sometimes things happen to them when I’m not on the wards. At those moments, I’m not fazed but what I do object to are the useless bleeps or the bleeps where you answer the call and the extension is engaged (Don’t bleep me and run off you twerp!) or, as happened tonight, the bleep you get when no longer working to attend to a job that the on call can do because they’re already on that ward doing other things. Me? Bitter? If you happen to ever need the on call doctor, don’t do what one nurse did to me today and bitch about me... to me. I kid you not. I was bleeped after I’d finished (half an hour past my official finish in fact) to write up Warfarin doses (hardly an emergency) and politely told them to write the job in the book for the on call doctor to complete since I was stuck on post take rounds and had actually finished my shift. Fifteen minutes later, bleeped again by another nurse to do the same job and, before I had time to say anything she said “We bleeped the acutes House Officer but he was too lazy to do it and said I should leave it for you since you’ll be sat on your arse” Astounding stuff! I’d said no such thing and I took great pleasure in saying simply “This is the acutes House Officer love, you bleeped the wrong number”.
So, the shine may have rubbed off the job a little bit today but, by and large, I still look forward to going in to work when I get up. If only I could convince certain wards that my bleep is a way of getting in touch with me for urgent jobs and not, as they seem to think, a toy for their amusement things would be as near to perfect as they’re likely to get.

On the plus side, one day to go before I get a week of annual leave! Huzzah.

[M Clayton]

And then Friday came...

Another typical day on acute admissions – there’s going to be a new Boss as of lunchtime but, for now, we’re engaged in the business of looking after the week’s admissions with fingers crossed that no eager minded GP Registrar feels like flexing his muscles to admit someone else. With Thursday being so busy, there are still a huge number of loose ends that need tying up before hand-back. Except, there’s not really going to be a proper hand-back because the House Officer that should be attached to the firm only exists on paper (why then do they have their own bleep when I have to share with J!?). I, therefore, will be responsible for the patients of two consultants – the first lot collected over the course of a week on take and the second bunch admitted acutely, some of them likely to be ill and demanding of a certain level of attention.

First up though, ward round. We’re doing well and I’m sure that this must be some sort of record – there are patients under our team scattered across 7 wards, only 3 of which are actually general surgical wards. It’s a good thing I have comfy shoes but my poor memory for faces does make it a tad difficult to work out which patient has which problem. At 8:30 I’m told to find the on call gastroenterologist and discuss our two patients requiring urgent ERCPs – both of them have astronomically high bilirubin levels and both of them have cancer (or will have once the radiologists have verified the scans). Neither of them yet knows that they’re in trouble and The Boss hasn’t really fired the warning shot – talk of “scar tissue” and “pressure from outside the bile system” don’t really highlight the fact that there are pancreatic masses. Anyway, that’s by the by – they need to have their biliary systems imaged and have stents inserted if possible – if we don’t move quickly, one or both of them is going to develop hepatic encephalopathy. This will be bad news for the House Officers on over the weekend and will probably mess up the patients’ day as well.

The gastro secretary informs me that the consultant is currently in an MDT meeting and won’t answer his bleep. The Boss informs me that I need to go down to the MDT and talk to him about our patients. Now. I don’t have the foggiest where the MDT is being held but our student is confident she knows the way. She will also go now.

We arrive and I plead our case. He wants to know the bilirubin levels and isn’t impressed when I recount them. Apparently, bilirubin that doubles daily isn’t grounds for an urgent ERCP and if The Boss wants urgent procedures, he should come and bloody well ask himself next time. Well and truly told, we make our way back to the ward round to pass on the bad news, fully expecting another ear bashing. Surprisingly, it never comes and I’m told to document what was said in the notes with a clear warning to any F1s that may follow that Mrs A at the least might well flip into encephalopathy over the weekend.

So far then, we’re having a bad day but it might be something we can save. Ward round finishes and there have been no acute admissions (phew) – I have only to order 4 (count ‘em) CT scans, 2 Ultrasounds and a raft of endoscopic investigations before I review bloods and look after the work experience chap. This is all doable and I’ve had a run of luck with radiology – none of my requests have been turned down so far and I’m feeling pretty smug. I’ve allowed myself to believe that I must write such great requests that they can’t help but acquiesce – I’ve very quickly learned the best way to get what I want and, yeah, I am good. Funny how it can all crumble down around you very quickly though eh?

The CT scan requests are accepted with just one caveat – I need to make sure that Mrs B gets a pregnancy test done before she goes downstairs. Sure, sure. No problem, we can get a urine test done pretty quickly and then she can be irradiated in the Polo. Still feeling pretty good, I move on to ultrasound and hit my first major snag. The sonographer isn’t sure that scanning the abdomen of Mr C is a good idea – he’s got a great big abdominal hernia and non functioning stoma with pain. What do I think I’ll see on scan? Why am I requesting the test? I reply honestly (it’s stood me in good stead so far) and say that I don’t know enough about the test to know but The Boss wants the test done. I am bumped higher – the radiology registrar will see me once he’s explained that the lump in a chap’s scrotum is just an epididymal cyst.

“No. Ultrasound is not an appropriate choice of imaging modality for this patient. We won’t do it”

Shit. I need this scan because The Boss has said we need it. He doesn’t ask if he’s not sure it’s important. How can I get around this? I try being polite. I try explaining my predicament. I ask what I need to write to get this test done. Nothing will be done. Eventually, I leave in the knowledge that I’m beaten and vow to come back once I’ve spoken to the boss at lunch.

It turns out that “lunch” is a continuing myth when my break consists of having a glass of water on the way from endoscopy to the ward for rounds. The Boss is harassed – he should have been in a meeting 10 minutes ago and he wants to conduct a quick paper round rather than seeing everyone again. I try to explain the lack of ultrasound and he responds by telling me that it has to be done today – no excuses. I am dismissed from the round with orders to get the scan any way I can. I limber up for round two in radiology and am rewarded for my efforts with an audience with Dr Y, the most crotchety consultant ever to be unleashed on a House Officer. He chews me up and spits me out. Then he starts again. I am “an Idiot” and I write “F@*king pointless drivel” on request forms. I got my medical degree from “a packet of Cornflakes” and I “definitely shouldn’t be a doctor”. Christ, all I asked for was an ultrasound. I tried to explain that The Boss had specifically requested this test not five minutes ago.

“Let’s call him. Dial him up. Go on, let’s see what he has to say”

After a few minutes of being passed round the houses, I manage to get The Boss on the line. He is not happy. The smug bastard radiologist settles down for the call. He can’t wait for The Boss to agree with him and confirm my status as “Worst House Officer Ever”. Protracted discussion takes place and the smirk is replaced with a grimace as the story is explained. Ten minutes pass and the still reluctant radiologist concedes that a “Reassurogram” would be appropriate given the scenario. He concludes with a promise to The Boss that I will be educated before being returned in one piece. On replacing the handset, he snarls at me and tells me that next time I won’t be so lucky. His wry smile tells me that he may well be right.

I need a sit down. In fact, recounting that incident makes me feel almost as small as I did at the time. I may well be an idiot but there’s no need to be rude, right?

Retribution came my way at 3 o’clock when I was called to the ward to see Mrs B by the nurses. She was in continued pain and wanted to know when her CT scan was happening. I was a little surprised that it hadn’t already happened so phoned the scanner room to find out what the craic was. I was placed on hold to the dulcet tones of green-sleeves before the technician returned with a bombshell – “Dr Y has reviewed your requests and has decided that they’re not priorities for today. We might do them on Monday but there are no guarantees”. My first thought was “Bastard!”. This was quickly followed by the realisation that I was going to have to explain this to The Boss and, more importantly, the patients. Oddly, the prospect of explaining to Mrs B that my promise of a scan today had been a lie worries me a hell of a lot more than The Boss. She’s going to go ape and I’m going to be exposed as the fraud that I am – honestly, what was I thinking when I allowed myself to believe that I was good at this?

There are tears and there are threats. There is the inevitable comparison with her own son (an SHO in the North) and then there’s the standard “I’ve got Bupa”. None of this helps in the least – she won’t be getting her scan and it’s my fault for pushing it with Dr Y. I should have accepted that the ultrasound request was a dodgy one and let it be. I am torn away from the ball of anger that the previously nice Mrs B has become by one of the HCAs – The Boss is on the phone and he wants a word with me. Crap.

He is miffed but he doesn't rant at me. I get the impression that this sort of thing has happened before but it still doesn't make me feel any better about it. Essentially, if the scan's don't happen today, they won't be done til after the weekend - two days is a long time when you're in agony. After an oddly protracted discussion, The Boss puts down the phone... just in time for me answer a persistant bleep from Ward 11. Our lady with ?Pancreatic carcinoma has just had her glucose measured - it's so high that the machine can't record it. "Have you dipped her urine?". They have and it's +++ for ketones. Great. Can this day get worse? I promise to come across immediately - DKA isn't something that's likely to wait very long.

Somehow, and I don't know when it happened, I've developed some confidence. I know what I'm doing - she needs a sliding scale set up and I write it up after I've examined her. I'm almost confident enough that I don't check myself but the nurse queries my use of normal saline rather than dextrose and I doubt myself for a second (come on, why would I want to give glucose to someone who's hyperglycaemic?!) so look it up in the Oxford Handbook. I'm right and I allow myself to feel good - this might even be a turning point.

[M Clayton]

Stable, I leave the lady and the ward behind. There's only half an hour to go before I officially finish my week on call and my first 10 days as a doctor and I arrive on the admissions unit to find a miracle has occurred in my absence. I don't know what he said or did but The Boss has sorted it so that all bar one of our scans is going ahead today. Suddenly, I'm Mrs B's new best friend - she thinks I'm a god. And I had nothing at all to do with it.

The final post take round finishes at 6 and I'm sure The Boss is going to give me some words of wisdom to take away (something along the lines of "work faster" and "don't piss of the radiologists again") but instead he slaps me on the back, shakes my hand and says, "You've done some great work this week. Even if you'd been here a year, I'd be impressed. Well done. Go home".

It's almost worth it, you know?

[M Clayton]

I'm back from my week of annual leave and things are better. I managed to get out and about with Nick and he really helped to calm me down after that final Friday from hell. It's no exageration to say that I was left both physically and emotionally exhausted and had to seriously give thought to my suitability for this job. After all, if I felt that bad after one day, how can I expect to cope with days under real pressure? But anyway, days out in York (beautiful city), Leeds (expensive city), Scarborough (erm, fishy town?) and Alton Towers (adrenaline filled theme park) soothed my nerves and, once again, I became able to see the brighter side.

So, this week, I'm back with my own firm. Mr M has only got a few patients on the wards and one in ICU and Mr W is on take. The bizarre system we have for dealing with acute takes means that I'm responsible only for Mr W's non acute patients - the poor house officer on for acutes take responsibility for anyone that lands between now and next friday. This has left me with the grand total of ten patients. Even better, they're all relatively stable thanks to James so all I have to do is chase bloods, site the occasional cannula and generally doss about. This is, of course, the calm before the storm and, this time next week, I will be a small pool of molten material halfway to China. But for now, we make hay while the sun shines.

[M Clayton]

We're a couple of weeks further on and a bit more experienced and settled. Ward work has become almost routine and, aside from my occasional battles with the radiology department, it's pretty straightforward stuff. Not too taxing but just busy enough to keep me from getting bored. I'm actually at that contented, "wanting to go to work in the morning" stage of life presently and it feels good. Of course, being paid £2000 a month to do something I enjoy doesn't hurt

Time to bring things up to date though, I feel.

It would be fair to say that I wasn't looking forward to last Friday. It would also be fair, and somewhat more accurate, to say that I had been actively dreading it. What then should inspire such feelings in me when the rest of the week had been relatively pleasant and easy going?

Handback.

A word designed to strike fear into the hearts of the surgical teams at York. Also a word designed to make your heart leap with joy. It very much depends on which side of the handback you find yourself. Those that'd been on the acute team all week looked forward to dumping the accumulated mass of patients onto the consultant's own firm before spending a leisurely afternoon looking after the lone patient that dared to be admitted during their final afternoon of the on call week. Those of us on the receiving end of handbook could only stand powerlessly by whilst the single side patient list of 10 or so long term, stable, chronic folk ballooned into a 6 side monster made up of acutely sick pre and post op patients. The absolute horror of it all.

So our handback was a total nightmare. Boss Number 2 (I really need to find a less cumbersome way to refer to the them don't I?) had managed to collect just shy of 40 (count em) patients over the course of his week on take and during our first post handback rounds managed to discharge a grand total of zero. There were a few familiar faces amongst the group since a lot of the folk we'd discharged quickly when I was on call had bounced back with the same issues... BN2 (does that work??) is a little more proactive and had taken them to theatre in order to remove some vital organ or other. Trying to deal with the 50 or so patients that I now had was a thankless task made worse by the fact that both my consultants had clinic, my reg was with them and my SHO had joined the acute team. Even my student deserted me! I won't bore you with excessive detail but I didn't get lunch that day and the constant bleeping of my pager actually managed to wear out the batteries - I really can't exagerate here, the day was that bad. But it was a Friday before a bank holiday, so I prepped some hopeful TTOs and prayed to the gods that deal with this sort of thing in the hope that the weekend team had the balls to get rid of some.

And they did.

Hallelujah, a manageable list.

[M Clayton]

(Written on Wednesday but due to various factors including being on call, not posted til now)

Er, how many days has it been? A few too many at a guess. Since I last wrote, there’s been a site upgrade so the question of where and how to blog has been raised – I’m a creature of habit so I’m probably going to stick around here for the time being but we’ll see.

Today, I renewed my long term love-hate relationship with orthopaedic surgeons. I don’t actually know what aspect of my personality/dress/face they don’t like but I’ve yet to meet an orthopod that has reacted favourably to my existence. This curious hatred has major consequences for me at the moment since my Foundation Programme educational supervisor is an orthopaedic surgeon. He seems like a nice enough chap but we’ve had an inauspicious start to our relationship and it’s abundantly clear that he’s not my biggest fan. I thought I’d sent him a perfectly reasonable e-mail asking if he had time to arrange a meeting with me to discuss educational objectives and his reply indicated that this had pissed him off majorly. Oh dear, thinks I. Not a disaster though, surely – I can recover this...

I pitched up in theatre as he suggested last week and was told he’d be out in half an hour. Fair enough. I went back to the ward and caught up with some blood results before heading back to theatre as agreed. The theatre was empty. The list was over and the staff had disappeared. Hmph. I did a bit of detective work and established that, contrary to what I’d been told, the surgeon hadn’t waited for me and had, in fact, gone home. Smashing. I love wasting my time.

The next day (Thursday sounds right), I headed down to the orthopaedic clinic since that’s where he said he’d be. All day. Every Thursday. Was he there when I went, nice and early, to check? Was he bollocks. He’s playing hard to get. So I arranged to come back in today, my day off in order to spend the ten minutes needed to get my logbook signed. “No problem. Eight o’clock in the theatre coffee room”.

8 am – No sign.

8:30 – No sign.

8:50 – arrival of consultant

8:51 – departure of consultant with orders to come back at midday.

Do we sense a recurring theme here?

Never mind. I’m able to see the big picture and, in the great game that is Hospital Life, I factor very low on the list of priorities that a consultant surgeon has. I just wish he’d not arrange to meet me if he wasn’t sure he’d have the time. After all, it’s not as if I don’t have my own jobs to get done. : / Did I mention that it’s also my day off?

12:00 – No sign

12:30 – Locate consultant as he “holds court” with another 3 orthopods. I take note of the sigh that ensues when he recognises that there’s no way out of this one.

“There are 3 things I want to say. 1. Don’t send me an e-mail again – there’s a hierarchy to hospital and juniors don’t e-mail consultants. I don’t care that my secretary is off indefinitely. 2. I spoke to one of your colleagues about you – he doesn’t know you very well but says you’re a grass. I’m not going to discuss it with you but if it’s true then I don’t like that aspect of you. No discussion. 3. One of the senior consultants rates you highly but that’s a minor thing. Now, where’s your paperwork.”

Signatures x 3 and we’re done.

Went as well as could be expected eh? : /

[M Clayton]

I should still be on call but the day House Officer has had a death in the family. Why should this affect me? Well, tomorrow, I will be both the day and night House Officer. Joy :/

[M Clayton]

The on call week is nearly over (this week ends on a Thursday for me) and I'm actually going to miss being on nights. The hospital is a very different place out of hours and, aside from the occasional nightmare, it sleeps pretty soundly (see what I did there? I used a metaphor ). I really enjoy being the "go-to guy" and the relative lack of seniors means I get to make a lot more management decisions of my own. Occasionally, I get it wrong but I'm learning all the time and my confidence is growing to the point where I'm able to manage pretty sick patients without needing to have constant supervision (at least initially).

Today was the day that I broke my 7 week stint without a death. One of our patients with disseminated cancer (unknown primary) passed away. Actually, that phrase, passed away, belies the violence and utter distress of the event. I've been present at a fair number of deaths now but this will live me for some time yet. The chap was relatively elderly and admitted yesterday with peritonism - discussion ensued between interested parties (consultant, family, patient, pall care bods) and it was decided that Mr X would not be treated actively. He would be for the euphemistic "TLC" (Why do they call it that? All we really do is pump them full of opiates and IV fluids - there's definitely no nurse cooing at their bepillowed side when the end comes) in the hope that he'd hang on long enough for the family to be gathered to maintain a vigil. I wrote up a syringe driver containing the usual cocktail and then attempted to get a cannula for IVT. I don't know what it's like at other medical schools but, at Newcastle, I was taught cannulation on those plastic arms (follow the needle mark of your previous 150 colleagues) or on healthy young medical students (My, what smashing veins you have). Never did anyone teach me how to get a decent sized needle into the arm of a patient curled into a ball of peritonitic agony so I did what I could and fudged it. Tiny, weeny, blue cannula in a relatively large forearm vein - I didn't relish the prospect of having to repeatedly stick the poor guy if I failed at my first attempt so I totally wimped out. I don't feel at all bad - it was sloppy, yes but I didn't think that he'd live long enough for the phlebs to chew my ear off. So, the stage was set and the actors were taking their place for the final act in Mr X's long life.

And he steadfastly refused to be rushed. Trundling along overnight, he surprised me by still clinging to his life as I left for home. And do you know what the worst thing is? I was actually a little bit disappointed that I wouldn't be the one to pronounce and certify him. Quite why I felt that way, I don't really know and I am quite ashamed to admit it. But there you go, we react to these things in strange ways.

Defying all odds, Mr X was still alive and seemed to be a little bit more lucid when I arrived this evening. I said my greetings and moved on to help the day House Officer with the backlog including someone that had been under my team just last week and had bounced with a rip-roaring chest infection. As I sat writing up the notes for this guy, Mr X's son popped his head out of the room and asked me to "just come and see dad, he's being a bit sick". I fully expected to drop in for a minute, write up some more Granisetron and then disappear to do more busy work. I did not expect a scene from The Exorcist - Mr X was busy vomiting up vast quantities of black, oily filth and was clearly in the throes of his terminal events. My shadow, sorry student, stood horrified so I sent her to take the family outside and grab me a nurse.

Nurse: "Oh my god! Shall I put out a crash call?"

Me: "No. He's not for resus."

Nurse: "But we should call the arrest team"

Me: "No, not for resus"

She clucked disapprovingly but stayed in the room. Meanwhile, Mr X had finished discharging his abdominal contents and was very purple all of a suddent. I flirted very briefly with the idea of getting some suction to his airway but it was all too clear that whatever mischief had befallen him had done. He was dead. Now came the routine.

Me: "MR X. OPEN YOUR EYES"

Mr X remained dead.

I vigorously rubbed his sternum. Nope, still dead.

Gloves on. Palpation of carotids - nothing felt.

Two very long minutes of listening for heart sounds with the cheap ass Toys 'R Us stethoscope from the crash trolley. Nurse was tutting. Clearly I was taking too long. It's a good thing that two minutes isn't a very long time because my ears were hurting. There was a surprising lack of silence - definitely no heart sounds but I could hear the tube rubbing against my chest as I breathed (a creaking, rubbery sound) and also, I fancy, the sound of decay.

One more step now guys, thanks for bearing with me.

Two more minutes of cheap steth action (I don't want to get black vomit on my own tubes now do I?) are followed by the confident proclamation that the nurse has waited a full five minutes to hear.

"There are no signs of life. Mr X has passed away. Death confirmed at 17:22"

As I left the room and the nurse with The Body (he is no longer Mr X, the patient, he has become hospital property until suitable disposal arrangements can be made) I realised that I'd been sweating considerably. I didn't think I'd been that bothered but I so intensely didn't want to get this wrong (can you imagine the headlines?!) that I'd gotten quite worked up during my assessment. Worse than the task itself was telling the family. Mr X's son, a massive guy with arms like treetrunks, cried. A lot. His wife did the soothing thing that wives are good at and I made some throwaway comments about Mr X not being in pain (**** off, he had vomited up his insides in his final moments - how could that not fail to sting a little?!) and that it being for the best (yeah, your dad is dead but, at least you're still alive eh?).

And then it was back to work and trying to explain why it appeared that Mr Y had bowels in his chest....