Medicine "oop North"

[M Clayton]

A month since my last post and I really don't feel as though as I've stopped - it's been bloody busy with one thing and another!

My last week of on call nights was generally, a poor show. My first night was filled with loads of those small jobs that take an eternity to accomplish without really stretching the grey matter. At some stage, I was phoned to be informed that I'd be cross covering the cardiology wards as well as my own block of elderly care wards. This was fine - I'd had some cardiology experience as a House Officer and covered the sickies on Coronary Care when I did my nights as a locum so I felt like I could cope. That changed when the wards started bleeping me about a man with a femoral sheath in place following angiography - easy peasy, thinks Mark - the sheath comes out and lots of pressure is applied at the site by a helpful passing HCA... Apparently this is not the case at Hull. There's a device that appears to be based on a toilet ballcock which requires a complicated process of pressure inflations and pulse checks and really seems to be a waste of time. Never mind though, I did as I was told and managed to survive my night of carrying two bleeps.

The next night was going to be better. I'd decided that I was going to get a bit of sleep and be stronger if asked to carry the bleep of another SHO. Predictably, this was not the case. The registrar covering the admissions unit phoned to say that the ward registrar (there are 2 SpRs on call overnight in Hull since the ward teams and the admitting teams are separate, unlike at York) would not be available and, unless my patients were in extremis, he'd not be available other than on the phone. Again, not a massive problem - irritating that the support seemed to be lacking but not something that we could do an awful lot about. So, I sucked it up and got on with managing patients as best I could until I got another call at half 1 in the morning. I was being summoned to the admissions unit since they were busy and missing an SHO. I was mildly annoyed, it's fair to say, but I did as told and traipsed over to "The Dungeon" (AAU has no windows and thus never sees natural light) to start clerking the backlog. The request that I see "just one patient" turned rapidly into a case of "while you're here" and it was suddenly half 5. No sleep at all and, crucially, no thanks. Hmph. More on this a bit later...

Another successful clerking?

The third night was a joy to behold. 5 hours sleep and some lovely night nurses!

But during the fourth night, I paid the price for a nice one. Cross covering renal was the first issue - I hate renal. Nephrology patients are, invariably, very sick and, invariably, very complicated. Most renal consultants are also very precious of their patients so it's not a great place to work when you're not experienced. It's even worse when you're tired and on nights in an unfamiliar hospital. Possibly the worst thing is that renal patients can arrive on the ward without passing through the admissions unit and they often do! I ended up admitting a chap who'd been transferred from another hospital without any clear idea why he'd been moved to us - he was no wiser than the rest of us so I made sure he was safe and left it for the day team to decide what to do with him. My night got worse at that point as I was crash bleeped to my home ward to deal with a patient having a seizure. A bit of diazepam quickly solved the acute problem but this chap had never had a fit before and basic bloods and examination revealed nothing obvious. I phoned the ward reg for advice and he promised to come over but hinted that I was about to be bleeped by the admissions unit... he wasn't wrong and I was order to, once again, get my arse to the dungeon to become a clerking machine.

Thoroughly pissed off with it all, I went home the next day and had my weekend off.

Monday brought a pleasant surprise in the form of a green envelope with beautiful copperplate handwriting. Inside was a thank you card (my first!) from a lady I'd clerked and managed during my first night(mare) on AAU. Heartwarming stuff and it made my week of hell worth it.

[M Clayton]

Go me - another month has passed by since a posting.

Life is so bloody busy at the moment. I do seem to be permanently on nights/long days/weekends and when I'm not working, I just cannot be bothered to put pen to paper (or, more accurately, finger to keyboard) in order to put down some musings. I will try harder but, as always, life has to come first.

Lots of exciting stuff to waffle on about - I am now an expert at managing the renal failure patients that the renal boys won't touch (for whatever reason). That some of these patients tend to languish and then die a few weeks later from aspiration pneumonia (why, oh why do they all aspirate?!) is neither here nor there - they have perfect u&es.

I have also perfected running to crash calls without actually running - it's embarrassing for the tower block teams when I'm able to arrive before them having clambered up 6 floors (care of the elderly isn't honoured enough to have wards in the monolith - we're stuck in blocks at the front and back of the site). My one "successful" arrest has turned out to be less of a success than I thought - he's a massive great advert for DNAR decisions - totally dependent due to the watershed stroke that followed his arrest and with no prospect of meaningful recovery. Great.

I've been a slave to the admissions unit when on call - frequently being dragged there to bolster a failing team (what sort of doctor just fails to show up to work without telling anybody?!) and, in the midst of the norovirus crisis, clerking in the corridors... happy days!

I have, thus far, avoided catching the deadly diarrhoea. That is all.

[M Clayton]

Today, I learned that I am "the most evil doctor on Earth" which was nice.

I had an afternoon of nonsense in clinic and my final patient was a ward follow up that I vaguely recalled from August. He'd been in with a collapse ?cause (a very common care of the elderly presentation) and had stayed long enough for us to rule out the sinister and acute problems. At the time, we'd done an MMSE which had demonstrated moderate memory impairment. A repeat today showed it to be worse and both his children agreed that their dad was losing his way slightly.

They moved onto his still driving at 92 and remarked that journeys that used to take 10 minutes in the car were now taking upwards of an hour - something he flatly denied. Along with the dangerous driving, he clearly demonstrated a number of other features suggestive of dementia. I discussed the case with the consultant and we agreed that a referral to the memory bods and a strong suggestion to stop driving were appropriate.

This is what makes me evil.

Apparently, taking away Mr 92's car from him means he can't see his girlfriend any more.

92 year olds have girlfriends?!

[M Clayton]

Good god, I feel miserable this morning.

Final hour of a nightmarish week of on calls - ostensibly as ward cover in Elderly Care but, in reality, clerking people in the dungeon at the same time as covering 120 old folk. For 10, terrifying hours, I was responsible for every medical patient not on the admissions unit - 4 crash bleeps on my belt, I was primed for the dolby surround sound moment of stereo cardiac arrest calls.

Luckily, there was no call (handy that too, not sure how effective my ALS would have been with just the one of me) but that's where luck ended. With the admissions unit at melting point, I've had no break overnight and have possibly ruined my relationship with one particular ward by calling them useless (in fairness, they are pretty awful) - I don't really care right now.

I need sleep.

[M Clayton]

Care of the elderly is done with and I'm going to miss it (well, most of it!).

Tomorrow night, I am thrown to the wolves when I start my 4 months as a paediatric SHO. I've done no paediatrics since I was a final year student. I cannot take blood from children. I cannot cannulate small children. I will be carrying an arrest bleep having last done paediatric ILS 2 years ago.

I am scared.

[M Clayton]

Isn't it odd how I seem to have settled into a "once a month" posting regime? It's a bit like the once monthly bisphosphonates that are coming onto the marke.... hang on, I need to stop thinking of such things. Children don't take Protelos or Calceos or whacking great doses of Furosemide (well, most don't!) - they take 15mg per kg of Paracetamol, the occasional 2 to 6 puffs of Salbutamol (via Aerochamber!) and a bit of nebulised saline.

I'm hugely more settled into the role of paediatric doctor now - a month where you're at work for 27 of the 31 available days will do that to you... Our rota has been absolutely unbelievable - I thought I'd been abused when on nights during my last placement but the lack of a full complement of SHOs has meant that we're all having to work extra shifts here and there to make sure that the on-calls aren't left uncovered. It's brutal and I'm currently at the stage where being off work makes me feel very uneasy - I'm on leave for the next fortnight (or I should be - I've been roped into covering paeds A&E for 2 days next week...) and I've already run out of things to do! What do normal people who don't work 60 hour weeks do with themselves? Telly these days is naff and I'm not sure I could read every story in the local paper every night...

Unfortunately for me, I joined paeds at the worst possible time of the year - winter is bronch season and the wards have been full of wheezy little babies in perspex boxes with a pretty high admission and discharge rate. It's done nothing whatsoever for my stress levels but I am so much more confident and comfortable that it's almost been a positive experience (note, almost). I can cannulate all but the most terrifyingly small of infants and I can usually get something to bleed enough to send off the basic bloods. I have ruined every Christmas ever more for one or two children (having blood taken by a bearded man in red and white on Christmas Eve will do that to you) but, by and large, I'm happy with my skills.

Now, If only I can get this bloody ST application finished, I'll be able to enjoy my leave...

[M Clayton]

I'm back at work now although it certainly didn't happen as intended...

My second week of leave was eventful, to say the least. I covered two days in paeds A&E at short notice for a colleague and, my god, I wish I hadn't bothered! Monday was a total nightmare (but not completely unexpected since Mondays are always bad in hospital) with a meningococcal sepsis arriving in resus at the same time as a first presentation of diabetes (DKA) and then a succession of sick children being referred. In the space of half an hour, I went from having an empty admissions board to expecting 2 pages worth of kids and, as it typical under these circumstances, they all landed within a short time period... ho hum. We managed to cope though, as usual. Tuesday was equally busy but a long stretch of the afternoon was filled with managing a 3 year old near drowning who was very agitated and very strong - she managed to tear chunks out of my arm while I held her for cannulation.

At some stage over the course of the week, I contracted flu (and proper flu, not a bit of a cold or man flu!) and ended up floored by it. The myalgia and fever was bad enough but when I developed pleuritic chest pain and rusty sputum, I did the only sensible thing... yes, I went to Newcastle to visit Nick! Nick is amazing but does not possess medical qualifications at all and, thus, my visit was simply made to ensure that someone would look after me. A weekend in bed (almost literally - I was up for 4 hours) filled with coughing, vomiting and the feeling of death was followed by a visit to a real doctor.

I had a left basal pneumonia - huzzah! That explained the pleuritic pain and filthy sputum as well as the sky high pyrexia - I'm sure I probably thought that was the case over the weekend but, you know, we doctors don't get ill...

[M Clayton]

Phew - just saved from the near oblivion of page 2.

I suppose you're wondering where I've been over the past couple of months... no? Tough, I'm going to tell you anyway.

As usual, the brutal paediatric SHO rota has killed all attempts at having a life outside of medicine (2 in 3 weekends on call with every other day a 12hr "long" are pretty hard going man) and I'm resigned to the fact that bloggery will continue to take a back seat for the foreseeable future.

My on calls have ramped up in intensity recently - there had been a brief lull just after Christmas and it seemed that we'd gotten through bronchiolitis season and had a gentle run up to pollen induced asthma season come spring. Foolishly, I'd neglected to pay the due respect to gastro season. For the last month or two we've been literally covered in shit and vomit and there have been some pretty poorly children. Unfortunately, there have been approximately 20 "well" kids to wade through and clerk before you see the truly ill ones that need to come in so huge amounts of time and energy are expended in order to prop up some "not so great" parenting.

On two occasions, we've come close to closing to paeds admissions with all our wards full to bursting point - last week, in a 14 hour period, there were 23 admissions across our 3 wards (may not sound like a lot but we only have 20 beds per ward and we share those with surgery!). We ended up with the consultant doing a ward round at midnight and then following that up by clerking patients in A&E with me!

In spite of the madness, I've actually rediscovered my love of paeds - our team is excellent and I really do feel like I'm good at what I do. I'm not sure that I could do this job forever but it's certainly a nice change from the relative drudge of adult medicine (I'm 100% certain that I'll be begging to come to back to paeds after the first week of my job in the dungeon...).

Back to the depressingly badly organised audit that I seem to have inherited from my predecessor then....

[M Clayton]

When last we saw our plucky hero, Dr Mark was rapidly nearing the end of a paediatric medicine rotation - we watched in anticipation as the weight of a poorly designed and executed audit threatened to crush his already enfeebled spirit. We all too acutely felt the impending doom of 4 months in AAU and it was at that point he dropped off the face of the Blogosphere.

Those of you that have read the fantastic novel that is Bodies will recognise the dramatic device that the protagonist uses to gloss over 6 months of surgery in what is, essentially, a book about life as a medic. Consider the 6 month hiatus my version of the same...

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So yes, I've been the crappest medical blogger in the history of ever - it's a good thing that I'm not prone to hyperbole... I freely hold up my trembling hands and prostrate myself before you in an act designed to garner your forgiveness and mercy. I admit that for the 4 months of my life as an acute medical SHO, blogging (and, therefore, all of you) were the lowest priority - possibly even lower than hanging those three pictures of New York that are still sitting accusingly on the floor of my study (they still aren't up). My excuses are legion but, essentially, boil down to the fact that I worked far more hours than was sensible, safe or conducive to a happy life. I could easily have spent 4 months bemoaning the lack of a) doctors (10 SHOs covering a 14 SHO rota); b) the quality of my colleagues; c) the quality of patients coming through the doors; d) the terrifying working conditions (including, but not limited to; the lack of natural light, the lack of ventilation, the paucity of equipment, the chronic shortage of nursing staff, the doctors office that had become the notes store and the overflow carpark of a corridor) and e) everything else about the world and everyone in it. I chose not to, not out of a sense of misguided loyality, but because writing it all down would depress me forever more.

However, I did learn a lot about acute medicine and developed some firm friendships - Stockholm Syndrome perhaps? - so it wasn't a totally fruitless exercise. Now that I'm free and have moved, blinking, back into the light, I can look back with a certain degree of fondness - there's a certain pleasure to be gained from draining ascites or manically trying to bolster the BM of a non accidental overdose of 600 units of insulin whilst also trying to write up notes for the other patient you were seeing before you said yes. Oh, and the never ending delight and sense of pride at getting a champagne tap - I'll certainly miss that. But, all in, life as anaesthetic SHO is the veritable mutt's nuts, and here we come to the crux of this current post.

I'm now working as a full time anaesthetic trainee and life is wonderful. I wake up some days and it feels almost as though I've died and gone to Disneyworld (the Florida one, not Disneyland Paris which is a bit lame really). I spend all my day in pyjamas and I'm only ever expected to look after one (maybe two at a push) patients at a time. My training is excellent and my colleagues are, so far, universally approachable.

It's going to be an excellent few years!

[M Clayton]

I've successfully completed the first of my four week on call blocks and can thus look forward to four weeks where I have my evenings and weekends completely free!

Anaesthetic on calls can be somewhat variable - days in acute theatres have been generally pretty busy but there's been lots of variety and I've managed to get loads of experience at managing sick patients in the theatre setting. The night shifts have also swung from one extreme to the other - my first night on call was filled with absolutely nothing of any consequence! I arrived as planned to find that the day team had cleared the acute list and nothing more was expected - that night, I did some studying, drank lots of tea and got loads of sleep! However, the SpR on call with me is known for his nightmarish on calls and the rest of that week rapidly became more like the endless nights on call in AAU - streams of sick patients needing lots of work and a complete lack of rest for the medical team. In spite of the pressure, I really enjoyed it and I'm keen to get on and do some more acute anaesthesia.

What else is there to tell you? We've had some amazing cases in theatre recently - just over 3 weeks ago, there was the patient that arrested in recovery, died and then came back to life 10 minutes after all efforts resuscitation had ceased! He walked out of hospital the next day with no memory of events and no apparent difficulties - I sincerely hope he bought a lottery ticket that week! I had my first "can't intubate, can't ventilate" scenario during nights - the simple laparotomy turned into a complete nightmare when I had a look and was met with a grade 4 view. This was followed by 10 frantic minutes as the reg tried every single method of ventilating and intubating the patient - we even managed to break the fibreoptic scope (oops!) but, somehow and against the odds, a tube eventually found the right hole and airway was secured. Again, the patient escaped unharmed and happy as larry but I'm not sure that I've ever heard anyone senior swear quite that much....

In life outside work (there's such a thing?!), I had a very busy weekend out on duty with St John at the Freedom Festival and Clipper Races in Hull. 190 patients over 2 days with 6 treatment centres, 3 ambulances, 30 first aiders and 2 doctors doesn't seem like a bad weekend's efforts at all to me. I had a fantastic time - did a bit of suturing, managed some acute medical issues, handed out piriton like sweets and even saved a life (probably). The best bit was driving my car on response calls through the road blocks but then, I am a big kid really...

Eurgh, my finger is oozing again - excuse me while I deal with this.

<Disappears to find a wipe and a plaster>

I should probably explain that last bit, no? Last week, I foolishly slammed the boot of my car (having already locked it) and managed to somehow trap the middle finger of my right hand - cursing the world and everyone in it, I was forced to fish around in the arse pocket of my jeans to find my keys and unlock the car before I could extract said mangled finger. Luckily, I didn't damage it too badly but I do have an excitingly deep laceration over the DIP joint and it's that partially healed laceration that keeps leaking serous fluid when I bend my finger. Gross, yeah?

Righto, I'm boring myself now so I shall leave it there. Pain round tomorrow followed by a big head-and-neck-ectomy in the afternoon. Wish me luck!