The Mystery of the Hole in My Lung: The Doctor Becomes the Patient!

It was precisely 20 days ago that I was at work. It was a Monday morning and I had just finished a busy weekend admitting medical patients from A&E. The Sunday was slightly trickier than usual – I felt like I’d slept in a funny position and my right ribs ached. Still, nothing like a steady stream of patients to focus the mind, and so on I cracked for the 12 hour shift. That night when I got home, however I could hardly breathe. Bent over double on the bed, panting like an expectant mother, I looked to my girlfriend with a glance that said “What the hell is all this about!” I am after all a fit, young(-ish) 32 year old with no medical issues. After failing to convince me to go back to A&E at 1am that morning – my argument being that I’d just spent 12 hours there and I am under no circumstances going back tonight – some knock-me out painkillers, shot of whisky and the classic of all medical inventions – the hot-water bottle (thanks, Mum), I fell asleep….albeit with a breathing rate of 30 per minute.

The next morning things were no better. Being the stubborn mule I am, I still refused to go to A&E – after-all we were short of team-members on the ward. Sadly however, once my registrar saw me hunched over like Golem from Lord of the Rings, puffing away at 30 breaths a minute, I was sent packing down to A&E. I had failed.

Now there are not many perks to being a doctor. With that said, that Monday three weeks ago, I was exposed to one of the greatest cornerstones of the NHS – comradery. You see as soon as I wondered down into A&E, had a quick word with the A&E registrar on the shop-floor saying that I needed an X-Ray to exclude a collapsed lung (that, since I am tall and skinny – well I prefer athletic! – a spontaneous pneumothorax was the most likely cause of my breathlessness), I was whisked into an A&E cubicle. Over the next few hours I had seen 2 A&E consultants, 2 A&E registrars, had a chest X-ray and CT scan, been squeezed into a respiratory clinic that afternoon to be seen by a Respiratory Consultant, and had the on-call medical team drop in to see if there was anything they could do. I was utterly humbled by the togetherness and sense that within the NHS, we look after each other. Now I say all the above not to anger people – and I appreciate some may dislike the fact that I had what is, yes, preferential treatment – but these people whom saw and treated me where my colleagues (for I had spent 4 months working in A&E) and my friends. Throughout the entire process, I spent my time wondering how I could repay them, to show my gratitude for their timeliness in treatment and kindness.

Now not one to be a debby-downer on the situation, let me tell you my two highlights of that day spent in A&E, CT scans and outpatient clinics. The first was the utterly bemused look on one patients face who saw me donned with a cannula in my arm, hospital gown on, being wheeled down the corridor – for I had been the doctor who had treated him only the night before! The second musing was the locum puzzled nurse (who didn’t know I was a doctor) who came in to see me in the A&E cubicle to insert a cannula, only to find me with my own stethoscope listening to my own chest, before defiantly stating that I will insert my own cannula thanks – though as it turns out that isn’t so easy, so I had him do it in the end. Being a patient was a huge eye-opener – you are devoid of control – something that as a doctor, I have a lot of. It brought a definite new respect for what it is like to be a patient. Plus, cannulas bloody hurt!

Anyway, we digress. It turned out that I didn’t have a collapsed lung. In fact it turned out that I had a 2.7cm hole in my right lung – described as a cavitating lesion. Now it is fair to say that this came as a surprise to the A&E team – and to me. What can cause a cavitating lesion like this?  Well, many things including infections like tuberculosis or a fungus. And yes, cancer can as well. This latter diagnosis kept me up for a few hours on that first night I got home befor, at around 4am, I decided that I should stop being an idiot – a 32 year old man who has never smoked, has no risk factors and no other symptoms of malignancy – does not have cancer. And so I put it from my mind from then on.

CT

[CT Scan]

The initial X-Ray

[Initial Chest X-Ray which we expected to show a collapsed lung)

Of course we still didn’t know what it was. The reward for not knowing was an investigation called a bronchoscopy. This is a way to look into the lung and take some tissue to look under a microscope. Now the best way to describe it is this: picture sitting upright in a chair, a little drunk, and then having someone funnelling a slowly leaking hose-pipe down your windpipe and your lungs….all while telling you to “just relax and breathe” in a tone that would be a hit in any yoga retreat. Let me tell you, it is NOT possible to relax…and as for the breathing…well, you feel as though you are drowning. Thank God for midazolam. It was fair to say this sedating drug did its job – I didn’t even recall the first conversation with the respiratory consultant after the procedure.

Post bronch

[Post bronchoscopy – Oh course, I have no recollection of this picture. Bad hair day..!]

Of course from that day that I went down to A&E to get that ‘quick’ x-ray, I have not been back at work. Why? Well, if I did have tuberculosis, I would be a huge infection risk – particularly as I am now moving into paediatrics – and those little people have far weaker immune systems than you or I. As such, while the hospital doctors that are treating me wait to see what bugs grow in the Petri-dish to see if it is tuberculosis or something else, I have to be at home.

Three weeks at home may sound like a luxury. It was hell. I felt a fraud, lacking in purpose, lost even. You see I felt well in myself after a week of antibiotics and guilty that I wasn’t at work. It made me realise how much I value my job as a doctor, how it is part of my identity and that I love that. I am after all, proud of being a doctor and working with such brilliant healthcare teams. Although, it is true that I became a very good house-husband over that time, the itch to return to work never left me. And finally after three weeks of waiting and waiting, I have finally been given the all clear to return.

After all that has happened, two questions do still remain: what IS that hole in my lung? And how can I possibly thank all the people that cared so much for me while I was converted from the doctor to the patient.

Only time will tell…

Nick

The Hospital At Night

It’s 0445am on Saturday 11th July and I am having a rare lull in my night shift. …

You know, the hospital at night is a unique, thought-provoking experience. It’s the time when all the hustle and bustle of the full complement of the daytime staff, relatives and heavy footfall across the WELCOME sign of the hospital disappears in the wake of silence and shadows. Instead you are left with a handful of nurses, doctors and cleaning staff echoeing their footsteps around the hospital corridors and wards. In a place which, during the day, you are side-stepping prams, patients, wheelchairs and stretchers, you can, at night you can stand uninvaded in the ground you hold.

That is one of the many reasons that I love night-shifts.

Now don’t get me wrong. This doesnt make me some daytime recluse, shying awaying from human contact – and daylight for that matter. I love it for it leaves my mind largely unitterupted to drift outside the box and ask – and try to answer – the questions that occupy my mind. Questions, that during the daytime, are drowned out by the emotional, physical and audible noise of hospital life.

For that reason, for me, at least there is a zen like state about night-shifts. You are one of a handful of doctors and healthcare members covering some 300 or more hosptial beds. You will – and do – get called to anything and everything. On a typical night I can expect to get called to a cardiac arrest (when someones heart stops), to possible new strokes, patients who fall out of bed, drug charts that need re-writing, family’s who need to be called to say their loved one is dying and they need to come in, and to write pain relief medication. All of these things indeed have happened since I started my shift at 9pm on Friday night.

As I go through a night shift, I find a very precious time. It’s a time to think about medicine, my career choices, – my life choices even. There is no magic to this – it is quite simply the silence of the night shift lets me do that. And to be honest, in a world that is as noisey as ours – with mobile phones and emails keeping us constantly connected – I welcome the opportunity for some peace and quiet. Of course, yes, the down side is that when it all goes wrong, and patients get really sick, and you are exhausted at 4am trying desperately to get a needle into their vein, the zen is gone, and the stress levels rise. You take the rough with the smooth.

I am sure I will be told I’m a little dramatic (well, my mum always says I have been one for theatrics even since I was a talking table in the school play) but I see the night shift as an adevnture! It is also a challenge for yourself. I like to see how well I can cope with the lack of sleep, with my body’s desperate desire to make me shut down into a low-power setting, and with the knowledge that I am part of only a small medical team and there is very little support outside of this. It teaches a certain degree of autonomy as a doctor and it pushes you to make decisions in the dead of night that during the daytime you could very easily defer to someone else. That ‘push’ makes us better doctors – and I would hope that means better patient care.

[15 minute pause in writing this]

As I have just learned too – the night shift is a rare opportunity to practice the things you don’t often get to do in the daytime; Like, as I have just done, to put a cannula into the vein of a screaming 4 year old boy. Now putting a cannula (they’re the tube that go into the veins to give medicine and fluids) in a adult can be tricky enough but when you are faced with an arms flairing, lungs open and vocal cords roaring, 4 year old grissler – it is an alltogether more challenging task. Still, after using two nurses and one mother to help me (and I must confess, on the second attempt), we managed to get the cannula in. In a vocal range that could rival Maria Carey, all it took to appease this little one was a sticker with a smiling panda on it. To be 4 again.

The sun is rising and the London is waking up once more. You may not all have a night shift to find your zen peace and quite but do try and find some part of your day or week that allows you the time to properly digest your thoughts rather than let them fester and give your brain indigestion.

Right, time for a coffee and a stroll of the wards….

Nick

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