Medicine "oop North"

[M Clayton]

Anaesthetics continues to be great, in general, although some of the theatre staff can be "difficult". Friday afternoon was an excellent example of the hysteria that can afflict normally sensible people when they perceive a potential injustice...

It was a normal afternoon in acute theatres with a steady trickle of relatively minor surgical cases finding their way through the anaesthetic room and into the hands of the surgeons. We'd had no surprises and no real difficulties and another routine laparoscopy +/_ proceed had been added to the list. I pre-assessed a young lady that the gynaecologists had seen - they were querying an ectopic pregnancy but they didn't seem convinced and the young lady was definitely far too well in my book. I planned for a simple GA with cuffed ET Tube and consented her accordingly.

So far, so good.

I popped back up to theatre and discussed the case with the reg supervising me who agreed with the plan and asked me to send for the patient. I had a quick chat with the rest of the theatre staff to make sure they were all ready and it seemed that we were good to go. As I was about to send for the patient, the acute theatre co-ordinator blustered into the anaesthetic room and demanded to know which of us was going to leave the room when the patient arrived.

When I asked what she meant, she explained that 3 men was too many given the "delicate nature" of the presenting complaint! The ODP wasn't going anywhere since it's his job to assist the anaesthetist and the reg wasn't going anywhere, since it was his list. That left me, a qualified doctor that had pre-assessed and consented the patient (in fact, the only person present who'd actually met and spoken to the patient!) to be thrown out.

Very frustrating indeed but there didn't seem much point in arguing. It's too early in the game to be making enemies of theatre staff even when they're clearly being ludicrous.

In other, exciting news, I got my first choice F2 rotation - Acute Medical Unit, Elderly Care and Paediatrics in Hull! Woo! Time to hunt for a flat I think.....

<hunting>

Apartment 1, 2nd Star on the Right and Straight on til Morning, The Land of Green Ginger

What a fantastic address! I must have it!!!

[M Clayton]

<I've been trying to post these entries for a while but various things have made that impossible. You're going to get a bumper crop over the next few days - don't think it's always going to be like this because it won't! >

Apologies for what follows but you’re probably used to my graphic rambling by now...

Anaesthetics is a sweaty business. At least, it is for me. At the moment, I’m finding that there’s usually at least one case per day that really makes me sweat and I’m not just referring to those patients where things suddenly go awry – the physical nature and concentration required for some of the stuff we do makes me, erm, damp. : S

It’s a bloody good thing I wear a t-shirt under my scrubs top because I’d have been the talk of theatre after my last central line placement! I was absolutely soaked and, once I’d cooled down a bit, more than a little uncomfortable. It doesn’t help that central line insertion is an aseptic affair and requires that you wear gown, gloves, mask and hat (yes, and the rest of the clothes you were wearing beforehand – how old are you? ) but the biggest reason for the level of perspiration is the simple fact that it’s ridiculously easy to screw up the procedure and cause quite major damage to the patient. Put simply, it’s scary stuff! The thought of inadvertently cannulating the artery or causing a pneumothorax means that I’m also very slow – the consultants can have an internal jugular line in at such a pace that you can blink and miss it whereas it takes me a good 15 – 20 minutes to achieve the same. I make a lot more mess doing it too...

It’s not just lines that make me sweat – on the scary occasions when I’m politely informed that I’ll be the one doing the rapid sequence induction (RSI needs to be quick – the longer it takes to get the tube past the cords and the cuff inflated, the greater the risk of a catastrophic aspiration of gastric contents) I get a bit hot under the collar. There’s always a terrifying moment when we seem to be hours into the procedure (in reality, it’s generally at 5 or 6 seconds after the reflexes are abolished) and I can’t see a bloody thing – the stage where it’s make or break. I’ve stepped away once but now I usually sweat my way through and get the tube in place through dumb luck (or judicious use of a bougie). My arms generally hurt for much of the rest of the day and it does take a while for my heart rate to settle but, bloody hell, it feels good!

[M Clayton]

It’s finally happened; I’ve had my first death on the table. I’m actually surprised it’s taken so long for me to be involved in such a case. After all, we do a hell of a lot of acute surgery on some very sick patients indeed – you’d think that we’d have people die fairly regularly. Of course, we’re pretty good at weeding out the folk that might cause us big problems so there are probably a fair number that never make it as far as the anaesthetic room.

A middle aged lady had been admitted a few days earlier and had had a diagnostic laparatomy that revealed no cause for her ongoing acute abdominal pain – everything had looked peachy and the surgeons had withdrawn, leaving the organs largely undisturbed. She progressed reasonably slowly over the next few days with a prolonged post op ileus but started to pick up towards the end of the week and plans were made to discharge her over the weekend.

On Friday, one of her legs died. Essentially, that’s the long and short of it – for those more technically minded; she developed an acute ischaemia of the left leg without apparent cause. The vascular surgeons were called and sent her for an urgent angiogram with the intention of stenting any clear blockage. After 4 hours of trying, they couldn’t get past the occlusion in the common femoral and decided that the only way to deal with the situation was to perform a bypass graft from the right side (fem-fem cross over) and she was booked onto the urgent list. At some point, the house officer for the team noted that the abdomen was very distended.

So, we got involved. Initial assessment on the ward was not encouraging – she was profoundly unwell; shocked and in a grave condition. Rather than mess about trying to get things sorted on the ward, we arranged for her to be transferred to theatre so we could start aggressive resus. In quick succession, we sited an arterial and a central line and secured her airway. With that in place, we were in a better position to start with fluid resuscitation.

Aside from being very dry, this lady was hyperkalaemic (with a potassium of 7) and very acidotic. In short, she was buggered before the surgeons even started to cut. But, nevertheless, we did what we could to correct the potassium and, initially, we had a bit of success. After a thumping great dose of insulin/dextrose and sodium bicarbonate the potassium dropped to 5.5 – still too high but no longer life threatening. Her ECG looked a little less scary too, so we allowed ourselves to relax a little. Everything looked reasonably stable with the invasive monitoring demonstrating reasonable cardiac functioning.

The surgeons got on with their job and, after an hour of firtling in the groins, they proclaimed the job done. We got a bit of warning and then they reperfused the leg...

The ECG changed quite quickly and it became rapidly clear that the potassium was once again, way up. I took another blood gas and had it run down to the ICU analyser but there was no point in waiting for it to come back - we had to treat the ECG changes as they stood. Cue more calcium, more insulin/dextrose and a last ditch effort with bicarb.

The ECG stayed stubbornly awful.

The surgeons descrubbed and went home.

The abdomen was massively distended.

And suddenly, she crashed.

We'd already got the defib ready but the rhythm was a non shockable PEA so I started chest compressions. An adrenaline infusion was started in a vague attempt to bolster the failing BP and an urgent call was put out to the GI surgeon on call. We had our suspicions that something horrible was going on inside that belly.

All pretence of sterility went out of the window when the consultant arrived on scene. He didn't bother to scrub, putting on a pair of sterile gloves and a mask as he entered the theatre. He began to cut while I carried on bouncing on the chest and it became all too obvious that we weren't going to have a favourable outcome when, instead of bowel, her abdomen was full of a necrotic mess.

With the agreement of everyone present, we stopped. What were we actually going to save?

A shitty, horrible end to a difficult case.

[M Clayton]

Weeks pass by and we're now firmly entrenched in summer - my blogging is never going to become as regular as it was when I was a lazy student with nowt better to do () so we're all going have to be adults about this and make do.

From an anaesthetic viewpoint, I've moved on from being the "Theatres" House Officer and have become the "General Duties" House Officer. What this has meant in reality is that I've now got the generalised awfullness that is the pre-assessment clinic and exercise testing session on Monday and Friday mornings. I have to endure a lot of waiting around whilst the specialist nurses take the history and bloods from the patient - I am then wheeled in like a well practiced performing monkey and asked to examine the patient. The vast majority of the time, I find absolutely nothing of any concern but, on the odd occasion, I have turned up an undiagnosed murmur/carotid bruit/pneumonia. Oh, and I sometimes get shouted at by rude GPs for daring to suggest that they review a patient's medication when a routine blood has thrown up an issue.... By and large though, I use these sessions to catch up on reading novels and generally get quite bored.

A couple of my days have been filled with maternity cover. My experiences with maternity as a student had been overwhelmingly negative so I didn't expect much from the time spent on labour ward... suffice to say that I was not surprised. Essentially, the midwives seem to view the anaesthetic staff as being epidural & spinal technicians. The level of hormones presents adds an unwanted tension to make things that bit more "interesting". I had a go at siting a few spinals with varying degrees of success and, I can safely atest, I sweat even more when there are two patients involved!

When I'm not in the clinic or covering maternity, I'm back in theatre although even that's been a little hit and miss recently. Various rota issues have meant that there have been vast periods when I've not actually existed as far the directorate is concerned! At first, the opportunity to have an afternoon in the library was great but it rapidly grew boring and I found myself butting in on lists that weren't expecting me - less than ideal really.

That said, I've seen some interesting cases (such as the lady whose bowel kept bursting during a diagnostic laparotomy or the 11 year old with persistant refusal disorder) and have had the opportunity to develop my basic skills to the point where I'm now pretty confident managing most of the stuff I come across during a typical list. I'm particularly pleased with my intubation - I've gone from knowing the theory but having no real skill to being pretty slick. I still hold my breath when I tube a patient though!

[M Clayton]

It finally happened; my clumsiness caught up with me and I did something sufficiently damaging to have myself become a patient at my own hospital.

Last Tuesday morning, in my haste to get to work in time for the morning teaching session, I managed to walk into a door... Now, you may be asking what exactly would be worth such an injury - right now, I can't even begin to remember, so clearly not all that exciting!

In reality, I didn't exactly walk into the door - it was taken by a gust of wind and slammed into me but it sounds more amusing if I say I walked into it. Even more amusing still, my consultant suggested that I tell people I headbutted the last patient that refused to let me cannulate them. At the time, it was far from funny - the force of the impact was sufficient to both knock off my glasses and make me feel very very sick. I walk into stuff reasonably often (I actually broke a pair of specs doing a similar thing last year) but never do any real damage so I was more than a little surprised when I couldn't see out of my left eye and that there was a considerable amount of red stuff on the floor.

Being a practical chap, I picked myself up and had a slow wander over to A&E in the hope that someone there would be able to have a quick look and make sure I hadn't popped my eye out of its socket or anything equally ludicrous. Alas, despite the fact that the department appeared empty, the guys there refused to see me til I'd booked in with reception and had been triaged like the rest of the civillians! I felt like a real lemon when, standing there in surgical scrubs and with a hospital ID badge round my neck, the receptionist asked me what I did for a living.

Me: "I work here. I am, in fact, a doctor"

Reception Lady: <snigger> "Take a seat doctor and someone will see you shortly"

I'll give the department due credit though - I was seen pretty quickly and didn't have to wait once I'd been triaged. The FY2, who had covered nights with me just 2 months ago, did a thorough assessment and determined that my blindness was the result of a bit of peri-orbital oedema and the blood was coming from a laceration to the brow. Nothing too serious and certainly nothing that couldn't be fixed with ice, dermabond and some analgesia.

Check out the significantly improved peri-orbital oedema and not so neat glue job

Jeez, that dermabond stuff stings though. It's like they're injecting your wound with red hot oil rather than sticking the edges together. It's also very messy and I ended up with rather a large blob on my eye lid that stung like hell when it was pulled off. The piece de resistance to this sorry show came in the form of "simple analgesia"... I informed them that I had a headache - nothing sinister, just the result of being smacked in the face by a heavy door but needing analgesia nonetheless. Rather than give me some paracetamol, I was given 60mg of Codeine! I've never taken opiates before and, bloody hell, they're horrible!

The dizziness was bad enough but when it was combined with vomiting, it was an unworkable situation. For the first time this year, I was sent home from work and told not to come back until I could stand up by myself... I think the consultant was also a little bit irritated by my disinhibited loudness but that may have been a side issue.

So, when all was done and dusted, I ended up looking like a bit of a thug and have lost a chunk of eyebrow. I'm reliably informed that eyebrows don't grow back in a quarter of people so I may end up looking like a 17 year old chav for the rest of my life. Ho hum.

Moral of this story? Don't walk into doors.

[M Clayton]

I'm tired.

It seems as though I'm always on call at the moment - in the past fortnight I've covered 2 surgical weekends and a week of nights in medicine so, I'm nearly right!

I actually prefer being on call to my day job at the moment - I'm playing at being the Intensive Care House Officer and my day appears to consist of ward round after ward round. When there are only a maximum of 12 patients, it can be a bit tedious...

There have been a few opportunities to get on and do practical things - my central and arterial lines have gotten good and I've finally cracked my fear of chest drain insertion - but, by and large, I do a lot of patient assessment and chasing microbiology results. Occasionally, I get to run to a crash call with the SHO and, if I'm really lucky, they let me manage the airway when we get there.

I'm quite keen to get on and move up to F2 now - it's just a fortnight away and I'm looking forward to heading back to Care of the Elderly. Hull will be different...

[M Clayton]

So, I'm now an SHO.

So far, so good. Not really all that different from being a House Officer - bit more responsibility and get to answer my bleeps with "Hi, it's the SHO on call for elderly care" but really, not a big leap.

I know I'm being crap but I just wanted to leave a brief message to indicate my lack of death.

More later!

[M Clayton]

I've been SHO'ing now for a little under three weeks and I reckon I've settled back into medicine and ward life pretty well. I realise now just how spoiled I was in ICU - a nurse per patient!? Nurses that are able to cannulate and take blood?! My God!

I'm actually enjoying being back in elderly care - it's surely the last truly general medical speciality - although things in Hull move significantly faster than they ever did in York. In an average week, we're discharging a third of the ward to various places - I seem to spend half my life writing discharge summaries!

The work is mostly reasonably routine - we only have a consultant round two mornings a week and the SpR lives in clinic so we're left to fend for ourselves on the ward. We, I should say, are 3 SHOs of varying levels of seniority - predictably, I'm the most junior but there's also a GP VTS and an FTSTA 2. Most days, we divide and conquer and have a round of sorts over and done by lunch time leaving the afternoon free to chase results and organise other bits and bobs.

I've been on call as well - working one weekend in four and have a long day once a week. My on calls have been... well, they've been variable! I drew the shortest of short straws and ended up working the first weekend - some really sick patients to contend with but, to the best of my knowledge, I didn't kill anyone!

In fact, I seem to have done a reasonable job of saving someone who looked set to cark it when he was transferred to us from a surgical ward. He had horrendous renal failure - acidosis, hyperkalaemia (178!!!), and creatinine of 400. I was told to do what I could to keep him comfortable but with the careful management of fluids over 2 weeks, his renal function is normal and he's woken up! He's not going to be walking out (he didn't walk in!) but he's still with us. It feels pretty bloody good too!

I'm now enjoying my weekend off before I head back for 3 normal days and then my first set of nights at Hull. Wish me luck

[M Clayton]

The morning after the night before...

I'm tired and grumpy and I've got blood mixed with shit on my shoes - I'm sure some NuLabour infection control fascist would be upset with me for this but dying patients tend not to respect such social norms as not bleeding all over me. Anyway, I don't have a spare pair of shoes so it's academic really.

As you may have gathered, my first night doing nothing but ward cover has been "variable" (I do love that word - it can mean absolutely anything in a health care setting). The night started with a prolonged period where all I did was take blood for APTTs and Trop Ts. Try as I might, I couldn't convince the wards that they had other jobs for me to do - my day colleague had just been too bloody efficient.

Making good use of my time, I started to reread The Fellowship of the Ring. I've still not managed to get past Bilbo's party without skipping through the lists (honestly Tolkien, what were you thinking - a rare slip in an otherwise flawless trilogy) but I made good progress and started to think I might like to get some sleep during my on call.

But first, I decided to pop onto my home ward to check on a patient I know the cardiologists are planning to put a pacemaker in. Bad idea.

There clearly wasn't something quite right going on when I arrived - first there were no staff visible at all and, this being a night shift, I'd expected them to be sitting round reading Now! and drinking tea (but seriously, the workload is reduced at night - most of the patients are asleep, no?). Secondly, the ward was very quiet and, this being a care of the elderly ward, it's normally alive with the screams and moans of the demented and disoriented. To find a ward utterly silent worries me more than a crash bleep - at least I get some thinking time on the way there! The final and most damning sign of impending trouble was the smell - the ward normally has a curious aroma of cabbage, damp newspaper, sweat and stale urine but above all that was that all pervasive and sickly sweet smell.

Malaena.

Somebody, somewhere, was emptying bloodied bowel contents. This is never good when you're the doctor - people start expecting you to do things. It's compulsory to get gowned up to the hilt and stick your finger in the poor soul's bottom, all the while wondering what exactly this achieves when you've seen the foul black stuff all over the bed (answer? It keeps the surgeons happy).

True to form, mere milliseconds after my arrival I was chased down by a stressed looking staff nurse. "Thank goodness you're here - I was just coming to fast bleep you. (uh-oh) Mr Y is covered in blood and we don't know where it's from - we think it might be from his catheter"

A glance in at Mr Y's room demonstrated that this was categorically not from his catheter. Have you seen Carrie? Perhaps it's too old a film for you to be aware of the particular seen where young Carrie is dowsed in pig's blood - let me assure you, it was nothing like that. It was much worse in that instead of fresh blood, there was also half digested black goo and a significant quantity of shit. This could be from his catheter?! I doubted it highly.

I did my doctory thing - demanded a set of obs and asked if he had access. The little nurse proudly pointed out the pink cannula that had been inserted in his right antecubital fossa and then wondered why I huffed out of the room in search of some serious needles. In the brief time that I'd been out of the room, Mr Y had managed to empty a further litre of what now looked suspiciously like fresh blood onto the floor around his bed. The staff (and by extension, I) were literally splashing and around in it trying to get him sorted - it's a wonder I didn't slip and end up jabbing myself in the eye with a 14G cannula.

Mercifully, despite his profound hypotension and raging tachycardia, Mr Y still had those wonderfully ropey old man veins that are easy to cannulate if you're in a hurry. In no time, we had fluids running and fast. Not as fast as I'd have liked though - my request for a pressure bag or two was met with "Where do you think you are? this is a care of the elderly ward!".

Various other things happened - I quickly realised that we were fighting a losing battle and asked for the relatives and the med reg to be called. Med reg dutifully arrived just as I'd ordered 4 units of O Neg and remarked on the futility of the operation. He'd managed to locate a set of notes that had previously been missing and had noted that Mr Y was, to put it kindly, not a well man. Our tact changed from one of rescue to one of controlled failure - the fluid of choice stopped being colloid and became morphine.

Calmness descended.

Floors were mopped. Sheets were changed. Chairs were thrown away for incineration. Mr Y clung to life for long enough that his family could say their goodbyes. And, in what had been a little under an hour from start to finish, it was done. Just one of many deaths in our little corner of the health service.

[M Clayton]

Clinic is brilliant!

The nursing staff treat me like a god - I get brought sweet coffee when I don't ask for it, they break out the fancy biscuits and I don't have to clean up after myself. To top it all, the patients are relatively healthy and I can get away with seeing four people in a four hour period - brilliant!

Afternoons in clinic rock