The Human Spirit.

It’s Monday. I should be sleeping since my week of night shifts starts this evening. Thanks, however, to the 18 inch electrician’s drill bit that is currently working its way through the downstairs flat exterior walls, and the road works outside – sleep is not an option.  The entire building is vibrating! But you know, I look at it with a peaceful mind.

Why?

Quite simply because when you hear of the tragic horrors of events in Tunisia last week (and similar unspeakable atrocities that go on around the world – heard and unheard of), you cannot but realise how precious life is. How precious our families are. How precious our friends are.

Yes we live in an era of instability, concern and unrest but we also live in a world where people are willing to look after others, to put themselves in harm’s way in order to protect to their very last breath those they love – and for complete strangers. We too live in a world where men and women display courage and resolve by trying to stop pain, suffering and distress – people who have no responsibility to even try – such as the builders who were throwing rubble down on the individual who committed those murders as he escaped through the streets.

The human spirit is indelible, strong and etched in all of us. We may walk around in a society where individuals fear to speak to strangers, where heads are held down and eye contact eschewed.  But when individuals are in real need, I still believe in us, I still believe in the human spirit, and that intangible innate call to protect and help.

I would never dream draw parallels to those events in Tunisia but what I can say is that at the end of every day in hospital, I leave with an albeit tired smile on my face, forcing myself to discharge the negativity that can understandable creep into my mind, and instead recall those small, unrecognised, moments where the human spirit shows itself.

Never give up on the human spirit. Please. We need it now more than ever.

Nick

Making The Decisions That You Didn’t Think You Could

There aren’t many sounds that can haunt me. In fact there is only one really. That, ladies and gentleman is the sound of the pager that I have to carry when on-call. Just to bring you up to speed, an ‘on-call’ is typically outside of the normal working hours when all the regular doctors that manage their respective ward patients have gone home – so after 7pm until 8am or, at the entire weekend. It is then the responsibility of the on-call team to respond to any medical issues in the hospital.

A medical on-call team consists a Foundation Year One Doctor (F1), a Senior House Officer (SHO), that’s me), and a registrar (with of course a consultant available if needed).  Between the three of us, we manage the entire cohort of medical inpatients – which in my hospital is a rather heart-sapping 300 plus patients.

So the weekend just gone, I was the medical on-call SHO. Saturday morning I clipped on the pager into my scrub trousers at 8am, took the final resignatory sip of my coffee, demolished a banana in one, and enjoyed the feel of comfy chair for a minute, knowing full well that I may not get to experience any of these simple pleasures for the next 12 hours.

And then it began.

“BLEEP BLEEP”

The first call was a patient acutely unwell, with oxygen levels dropping below a safe level to oxygenate organs like the heart and brain. I told them I’d be right there. However, as Sepp Blatter knows all too well, life doesn’t always work out the way we want. “BLEEP BLEEP” – a second bleep echoes from my scrub pocket as I’m walking towards the rapidly oxygen-starved patient. The voice at the end of the mobile when I call the page number tells me they have a patient who has just spiked a temperature, has a heart rate of 140 (and they’re only lying in bed not running a marathon, remember) and a blood pressure low enough to be in their boots. Still walking towards the first patient I was bleeped about, I tell the anonymous nurses voice I’ll be there as soon as I can, to push some fluids through the patient’s drip, and put up some paracetamol through a drip. They tell me they need me there right now.  Sorry, I have a higher priority patient. Brutal but true.

“BLEEP BLEEP”, “BLEEP BLEEP”…two more bleeps come through as I arrive at the first patient. The nurses on the end of the phone I speak to (as I am mouthing and pointing to the other nurse at our first oxygen starved patient to put the high flow non-rebreathe oxygen mask on and crank up the oxygen in a fashion that explains why I was never any good at charades) deliver me two more blows – a patient has fallen out of bed and has a deep laceration to the forehead and is more drowsy, and another patient on the coronary care unit has central crushing chest pain.

Those four patients were a snapshot of my first 25 minutes on-call last Saturday. My coffee was probably still warm, and my comfy chair still with my bum impression on it. How things can change so quickly!

Plus, I had 11 hours and 35 minutes left of the shift.

Now many of you may be expecting me to be writing this from some padded cell, drowsy from sedative, with one arm of out the straight jacket, having completely lost my mind at such a weekend. However, I am pleased to say I am not. In fact, I am sat in my living room enjoying the buzz of Londoners as they comes to life for another busy day in the Big Smoke. I have, you see, experienced many weekends like this now. The first few, I must confess, I did not cope, became stressed beyond my own expectations, and returned home feeling like I had not only let down my patients but let down the perception of who I thought I was as well. I am not sure which one was worse. It left me with many sleepless nights.

But experience is a tricky beast. You see you have to give yourself enough experience to really grow and adapt. The second and third on-call weekends were still too early in on in my experience journey to truly get to grips with how I was adapting, learning and growing.

Then I started to get better. I started to see my clearly what patients were critical requiring IMMEDIATE response, what patients were URGENT but not critical, what were patients were IMPORTANT but not time-sensitive, and what patients reviews were NOT ESSENTIAL (if time were to run out). Now I can fully appreciate that to many this can seem callous. The truth is that you quite simply have to see patients in the order that they are most likely to die.

So, my patient with low oxygen was at greatest risk, then the low blood pressure patient, then the chest pain (possible heart attack), and then the head injury. What I haven’t mentioned is that as an on-call doctor you begin to work out what you can do remotely over the phone. So, while I am seeing the low oxygen patient, I can ask the nursing staff if they can give the low blood pressure patient some fluids through a drip, put them on a heart monitor, have 5 minute cycled blood pressure measurements, and ask them to page me again if it falls below a certain number (e.g. Systolic Blood pressure of 80). For the chest pain I can ask for an ECG (a heart tracing), heart rate and blood pressure, and give them some medicine to relieve the pain. For the head injury I can ask the nurses to get the patient into bed, put a pressure dressing on the laceration and do half hourly neuro-observations to make sure he isn’t having signs of a bleed within the brain. The reality is, I may not get to some of these patients for well over 90 minutes.

So I suppose the bottom line is that life as a weekend on-call as a doctor has taught me some lessons that we can apply to all walks of our lives:

  1. We can’t bend time
  2. We can only be in one place at a time
  3. Stressing about what is beyond our control is a waste of time
  4. The more stressful and heavier the workload becomes, the calmer you need to become
  5. Indecision is worse than the wrong decision
  6. A sense of humour goes a long way

I am definitely still a work in progress (I know this as I still have the most vivid, real dreams of patients I have seen the nights after an on-call) but I sit back this morning with a smile on face, feet up on the sofa and a coffee in my hand, knowing that I am stepping in the right direction.

Have a great week.

Nick

Doubt

It happens every 4 months, so by now I really shouldn’t get surprised by it – I am transferred on my conveyer belt of doctor training to a new specialty in medicine. The frustrating thing about this move is not that I am resistant to change or experiencing new and fascinating (ok, maybe not always) aspects of medicine but rather that 4 months is just the right about of time to be settled into a job. At 3 months, 3 weeks and 6 days I know the regular staff, the working day routine, what to do and what not to do (and the definitely what not to dos), and I am essentially settled. Life is good.

Then, all of suddent as that 3rd week of the 3rd month rounds itself off to the odd 7th day, suddenly the trap door opens below me and I am dropped into a whole world of doubt. 

You see what happens is, you finish one 4 month rotation on one day and the next (typically a Wednesday so that you can only do so much damage in the three days before the weekend) you start a brand new one. The treadmill on the new rotation doesn’t start on a slow speed with a gradual incline – it starts at 100% incline and break neck, eye-watering speed. Last Wednesday I was all of a sudden presented with thirty complex medical patients whom I knew nothing about, a ward that I had all the orientated ability of school kid on day 1 of their duke of Edinburgh scheme -and to cap things off I had my lucky pen had run out of ink. Never underestimate the importance of a good pen.

As first days go it was, well, awful. How do I measure it? Well, there are lots of parameters from the number of patient left alive at the end of a day, the number of relatives who have shouted at you, the number of toilet breaks (the number of toilet breaks inversely proportional to the busyness of the day), or the ability to consume food – more than the last Haribo sweet on the nurses station that has by that point been grazed by a two dozen partially washed hands and splashed with a hint of alcohol hang gel-MRSA fusion. That first day was however measured by the ultimate yardstick – the time you left work. In the case of day one of my new rotation this was a punchy 2 hours and 15 minutes after my shift formally finished. 

Joking aside, I am really not a fan of this swap period. It’s not because the new medical team are not nice or receptive – far from it – or that I have some longing to remain in my old rotation (as much as A&E was amazing, I’m glad to get my weekends back) since I am naturally hard wired to want to stretch myself – whether I enjoy it or not. The reason, rather ashamedly is that I always end up getting floods of doubt about my skill as a doctor.

The start of a rotation is always very exposing you see – it is raw, fast paced, unforgiving with time not waiting for you to catch up or get up to speed. With this fate I inevitably end up judging myself harshly, filling with doubt and worrying about my skill as a doctor. As such it was fair to say I hated my first day on the medical ward last week – an assault on self-perceived professional competence. Now as someone who sleeps like a log (and I mean really does not move until they awake with that tiny pillow-pool of dribble cradling the nights saliva) it rare for me to sleep badly. 

The first two nights after I started this rotation I slept awfully. Definitely no saliva pools but instead replaced with sore eyes that had stared at the ceiling of my childhood bedroom (home for Easter for the free chocolate obviously) from 3am until sunrise as I ruminate and dwell on the 4 months ahead. On the third night however when I awoke again at 3am I had a change of heart:

Sod this.

Having been enthralled with a bit of Bear Grylls Mission Survive on TVS the night before, I asked myself how can I survive better and change my mindset? This sounds ridiculous to many I’m sure but recognition of a problem, whatever it is, is the first step, however you find it. Plus, we all seek inspiration from different sources – and for me, not in an idylistic way, but more a respect of what he represents, find this in Bear Grylls. With that said, not to sound like narcissistic (something I’ve been accused of in the past) but I believe my parents have raised me and my brother incredibly well and given us all the tools we need to face challenges. So with this in mind at 4am I wrote a list. Now, I may regret this as I know some of my colleagues are aware of my blog now and may read this – but if I want to be truthful to the blog – I need not let that worry me. So here is the exact list I wrote:

  

We all encounter challenges in life; From the complex to the mudane. How we approach them is effected by an abundance of factors some of which are simply beyond our control. Someone once said, “if you can’t change something, then change the way you feel about it”. Composure, calm, positivity, tenacity, focus, good humour, all supplemented with support and teamwork, are all essential to win over any doubt that may creep into your mind. Looking after the body and mind with good hydration and nutrition is as critical too – unless of course you want to run your batteries dry.

I can succeed in this rotation just as you can succeed with whatever challenge you have this week. So with that, knock away the negativity and doubt, drive in the positivity and I’ll see you on the other side….

Nick

Back to (Relative) Normality

After 4 months, 75 shifts averaging 10 hours each, no social life and a strange new appreciation for daytime television and solitude, I have finally come to the end of my rotation in the Accident and Emergency (A&E) Department. The cloak of darkness is lifted and once again I will be returning to join Londoners on their daily morning commute; this a far cry from the 3pm, 4pm, or 10pm nocturnal shuffle that I would make towards work to start yet another evening or night shift. Weekends, ah weekends, how I look forward to you as well – no longer dominated by the quandary of how to get to work with the inevitable weekend rail engineering works but by which side shall I lay on as I doze, enjoying a lazy Saturday morning in bed.

I recall looking at my rota, some 4 months ago, and being filled with both horror and confusion. Afterall – surely I am not expected to work 6pm until 2pm Monday to Friday and then 3pm until 3am on Saturday and Sunday with only one day off before starting again?! Oh, no wait, I am. Now, however, I look at the rota with a real sense of pride, puffing my chest from a much diminished frame (I realised I have lost over a stone and a half since working in A&E), for not only have I had a the most fantastic time working in A&E with a wonderful team of people who encapsulate the Commando motto of “cheerfulness in adversity” (thanks Bear Grylls, for that nugget) but I have survived probably the hardest rota that I will encounter on my road to becoming a GP. Now if you didn’t know, I have spoken about life in A&E recently this week in the Independent (http://www.independent.co.uk/life-style/health-and-families/features/life-inside-ae-the-highs-the-lows-and-the-grief-is-something-that-echoes-across-all-hospitals-around-the-world-10132683.html) What I perhaps did not mention though was how humbling a place A&E is. Once you look past the chaos, the shouting, and the stress that, on some shifts more than others, seems to hang in the air, there are acts of kindness and compassion in all direction. Too many to list and perhaps, moments like that should be left in their moment and not revisited.

Last night, there was however, one patient that made me think about the appropriateness of some medical decisions we make. A 90 year old nursing home resident with advanced dementia, bed-bound, requiring all her care needs supported by somebody else, with bed sores, and a DO NOT RESUSCITATE order in place (at the wishes of this patient herself) is rushed into the resuscitation room via a blue light ambulance for a reduced level of consciousness. She had no temperature, was not infected. She had not appeared to have had a huge stroke. Looking at her, with all the information available it was clear that this was an old lady who was quite simply dying. She was in her comfortable nursing home with her own room, nurses that knew her, photos of her family and memories that she had sadly slowed had taken from her as dementia gripped. Why the hell bring her into a packed hospital ward to die. After talking with the family it was clear we all shared the same view – get her back to the nursing home to have a good death. Yes, a ‘good death’ is part of good medical practice as important as the life before it. A good death has comfort, dignity and is free of pain and distress. My point is, we should not treat everything and everyone just because we can. We have a mind, emotions and sense – let’s use it.

In an NHS era where I was supposed to make sure that I have seen and treated my patient within 4 hours (and by the way, referred to a medical or surgical team within 2 hours – tricky if you don’t get to the see the patient because there is nowhere to see them in a full A&E and when you do – they are already on 3 hours and 20 minutes), we, as doctors and health care professionals, are always expected – dare I say it pressured sometimes – to treat patients as a statistic. A statistic that we are desperately trying to keep below that horrible bloody number – 4. If I hear someone mention 4 hours this, 4 hours that, anymore, I may have to defect to Australia – and I don’t do well in the sun. Personally, I am refusing to treat any patient as a statistic – and if that patient breaches the 4 hour mark then so be it. My justification – a guarantee from me that they have received the appropriate care and investigations in a sensibly, safe and timely manner.

Perhaps people need to be reminded of the old Aesop’s fable – the tortoise and the hare.

Have a great weekend everyone,

Nick

The Winter Hibernation is Over

I feel a bit like the guy that never returned that phone call after a good date – but here I am, writing to you all after vanishing for nearly five months. Last time we spoke I was in general practice, sipping tea in between patients and enjoying my evenings with friends. GP life certainly has a lot to offer in that regard.

For the last four months though I’ve been in Accident and Emergency. I’m emerging from this nocturnal world (as 80% of my shifts finish after midnight) more battle-hardened for the medical world. You need a dislocated thumb or shoulder yanked back into position – I’ll do that; can’t get any blood for a blood test from the arm – don’t worry I’ll stick s needle in their groin artery to get some; want me to take the next patient coming into the resuscitation room with an overdose – I’ll do that (with some help of course!). 

Behind all the media public flogging of A&Es around the country there are teams of wonderfully dedicated, hard working nurses, porters, radiographers, health care assistants, families and doctors (the list is of course much bigger!) on the A&E ‘shop-floor’. I’m very proud to be part of it.  And what an eye-opener it’s been! I’m been exposed to the very best in human kindness, love, respect and loyalty  – but also the very worst. I don’t apologise for saying this but I definitely prefer to focus on the former – for my own sanity more than anything else.

My final bit of very good medical news is that I have been accepted onto the General Practice training programme. This means in three years I will (alarmingly) be a qualified GP. Now I don’t intend to become just a good GP – I’d love to continue writing more about my life as a doctor and health too….who knows’ maybe there’s even a book in me somewhere…

Take care

Nick

Gut Feelings

It is interesting, the notion of a gut feeling. I searched online to find a definition this morning (don’t worry, no patient neglect – a week of annual leave), and found this: “an instinct or intuition; an immediate or basic feeling or reaction without a logical rationale”. We all experience gut feelings from time to time. Some ignore them, some never realise they are present, and some act on them with an almost religious vigour. The rest, including me, pick and choose when to act upon them – with some gut feelings stronger than others. Hollywood loves a gut feeling – often some hero or heroine making the improbably ‘call’ and saving the day.

Like in medicine is definitely less ‘Hollywood’ than this. Yet this week I have found myself relying on my gut feeling quite a lot. Amongst the string of viral colds, muscular aches and sprains, and medication reviews I came across three patients whom I was on the fence clinically – that is do them need further investigations urgently or sending straight into accident and emergency. As a result of sitting on the fence clinically, which is based on my albeit limited clinical experience to date, I turned to how I felt about the patient – what my gut feeling was.

Now to digress just briefly – in medicine, you have gut feelings all the time. As a ward based doctor before I went into my general practice rotations, I experienced them a lot. It is classically the ‘end of the bed test’; This is where you will quite simply look at the patient from the end of the bed and they just don’t look right – or they look different from yesterday – just something, something you can’t put your finger on, and that the vital sign observations do not reveal. You have probably experienced these at work, with family or when out and about – you look at someone, something, or a situation unfolding and your gut tells you it’s not comfortable and you need to alter what you were about to do. I am sure, in medicine, as we doctors gain more experience, that this gut feeling becomes better trained and more refined. It’s the skill that medical school, like breaking bad news of a death, just cannot teach you in real life clinical practice.

So back to my three patients in GP surgery this week – The first two were both children both under the age of 2 years (one was just 10 weeks old). They both had non-specific symptoms, a bit of a temperature but not much – but then mum was on antibiotics for a bacterial chest infection – and when I looked at these little ones, they just looked a bit drowsy, a bit too pasty – and the whole story just didn’t feel right. When I examined them (these are two separate cases by the way), both didn’t reveal anything floridly alarming, perhaps a few added crackles to their tiny chests, the 10 week olds of which was no bigger than the palm of my hand – my stethoscope was huge when compared to her tiny frame. Not happy, I picked up the phone, and for both discussed the cases with the local on-call paediatric registrar. Both conversations resulted in the same outcome – both patients were transferred to A&E for speciality clinical reviews. I am still awaiting the discharge letters to see what happened to them.

The third patient was a little different – a man in his 50s. He came to me with a sore throat. Now in cold and flu season this is not an uncommon presentation. When, however I looked at him, he had yellow (referred to as ‘jaundiced’) eyes that indicated potentially a degree of liver disease, and when I examined him mouth and throat he had thrush. Oral thrush in a 50+ year old man is not common. In fact, it is a worrying sign. My gut was telling me that something very bad may be going on with this patient. On further discussion he had lost weight (not deliberately), coughed up blood in the past, smoked a pack of cigarettes a day for as long as he can remember, and drank to dangerous excess. When I sat in front of this patient, my gut said this is a serious case, and once I had that clinical information it only confirmed my gut. This gentleman was sent urgently for specialty review under the cancer two week wait rule.

So there we have it, a week of being more aware of my gut than usual. It is a wonderful, unexplainable tool that we all possess. Sometimes it works well for us, sometimes it works against us. This week, mine had been an ally that’s for sure.

Have a great week everyone,

Dr Nick

Disappointment, Grace Jones and The Reality Check Needed

This week has been a cracker in GP. I have seen such a melting-point of conditions that I am have never been bored; from otitis media (that’s a middle ear infection) which I managed to diagnose based on the patient’s symptoms and (more excitingly) the bubbles of fluid I saw the other side of her ear drum – a first for me, to the young teenager who I am pretty sure may have something known as slipped upper femoral epiphysis (known lovingly as ‘SUFE’), in which there is slippage at the growth plate in the long bones of the legs. Now this was interesting because I saw this teen the day before and his symptoms were fairly non-specific so I initially attributed them to simple growing pains – but at 3am that night, I woke up and couldn’t shake the fact that SUFE can be so easily missed that I didn’t want to chance it. I arranged the hip x-rays for him the next day. You have to act on your gut sometimes, I’m learning in medicine, even if it turns out to a false alarm.

So, yes, all in all a good week for me. However, that’s not what I really wanted to talk about in this week’s blog. This week I want to talk about disappointment and some re-grounding that I expect was needed for me. So for those of you who have perhaps just started reading my blog, I will just contextualise this a little for you. I, as a very junior doctor had some opportunities to be on a television programme about medicine. I jumped at the chance – simply because I love talking about health – and, yes, it was exciting! I have spoken about it a few times on my blog over the months if you ever want to track back and see the beginnings of how it came about.

This week however, the bubble was somewhat unceremoniously ‘popped’. Firstly, on Monday I learned that a VIP invitation that I had received to Grace Jones’s concert and dinner at Annabelle’s in London (a very swanky club that even my mum and nana remember!) with a host of celebrities, was indeed a mistake. It turns out that they thought they were inviting Nick Knight the famous fashion photographer!!! When I received the call telling me this (having of course told mum, invited someone very special to be my plus one, bought a fancy new tie and got my suit dry-cleaned), I have to say I did laugh! It was funny because I couldn’t shake the feeling that it was a bit odd…I mean seriously, why would I have been invited! Still, at least I avoided some horrendously awkward chat if I had actually attended – sporting a complete look of confusion as they tell me that they “love my work”…as I reply with “well, I just prescribe antibiotics, really”…! Needless to say when I told my mum she couldn’t help but cry with laughter. It was funny and I must admit when I opened the papers the day after the event to see Kate Moss stumbling out of the gig and Harry Styles with his shirt has off (or is that the style, I’d don’t know….), I did feel quietly relieved – that’s really not my scene. I smile as the whole scenario reminds me of when I mistakenly received an email from an Expedition Medicine company I used to work for who asked me to come out to the jungle to help teach the jungle course in Costa Rica. Of course, as a final year medical student at the time, I though that was a little ambitious! Turns out I was right, the email was meant to go to “Former Special Forces Doctor Nick”! At least I hadn’t booked the plane tickets…

So that was wake up call number one. Number two was when I learned that the television show I was on, and was being aired currently…has been taken off air. Turns out I may be too ugly for TV! Haha, no sadly, although that may be true, the fact was that the show was not performing and unsuitable for the prime time slot. It may well see itself on in a different slot…but I remain to be convinced of that. It was disappointing but I can take huge positives from the experience – including most importantly how I want to reflect myself as a doctor on screen (if I were to ever appear again). I also learned, even from this brief initial flutter with television that I need to develop a bit of a thicker skin when the people I know discover it and well, are not always positive. Criticism is something I have naturally never coped with well and I guess, at 31, maybe it is time to start working on that.

So two wake up calls this week. It hasn’t for a moment dampened my hunger to see if I can combine medicine and media – again, all for the simple reasons that I love talking about medicine and health – it touches us all in so many different ways, after all. However, while the slow wheels of media churn away, perhaps throwing up another opportunity in the future, I am very very happy. Currently I am having a bit of a love affair with medicine – I am enjoying being a doctor, made curious by my patients, am excited for a future in general practice – and, dare I say it, even looking forward to how much I will see and learning in the Emergency Department from December to March (even though that means working every one in two weekends!). The applications to General Practice training scheme opens next week so I am eager to get that submitted and start working towards the selection exam. Hmmm exam – sounds dull – but actually it is a great excuse to better my clinical skills even more…and the way that I am feeling right now – well, that’s no chore. Nothing is when you are passionate about it.

I hope you all enjoyed a particularly creepy Halloween as well!

photo

(My attempt on a quiet Friday Halloween eve!)

Have a great week everyone and try to fight any Seasonal Affective Disorder creeping into your days.

Dr Nick