Children as patients….

So I am currently in the middle of 7 days of night shifts – and with that I have to confess – this screen is a little blurry and I, well, a little grumpy today.

I wanted to share a story with you from last night. It highlights a number of lessons:

1. Never work with children

2. Never work with children

3. Never try and stick sharp objects into children with the parents standing over your shoulder

4. Never do any of the above at 1am

The night shift was pretty steady last night – a few patients having elevate temperatures (‘spikes’ in the business..) that required reviewing, a few patients to see in accident and emergency (including one torn scrotum that brought a tear to any mans eye) and then assisting in surgery for a laparoscopic appendicectomy (I have to admit, not wanting to be a surgeon, I find surgery a little dull!).

Then, just as I sit down to be absorbed by the teleshopping channel in the doctors mess, the goes off the bleep. Addmittedly this spared me from buying the super mop on sale, however,  I immediately recognise the number. It’s the kids ward. I look out the window for a second wondering what life would have been like had I become a vet…before finally answering the bleep.

It’s a kid. Eight years old. And his cannula has tissued i.e. come out.

These words combined are a nightmare.

What it means is, at 1am, I have a grissly 8 year old boy whose cannula (the tube which delivers fluid and medicine into his veins) has come out. And his father is there. Double nightmare.

Why you might ask? Well let’s put it like this – I can put a cannula into most adults but children are a pscyhological warzone. They cry, they shout, they lunge their arm out the way as you try and insert the sharp tiny object into their arm, make you feel just like a dreadful human being, and the parents shout at you in disbelief as you appear to actively trying to harm their child.

This, what I have described above, ALL happened. And it all happened at 1am. The precise time I am pretty sure the final embers of my caffiene fix also ran out.

As I kneel by this poor boy’s bed in semi-darkness, with the father shouting over my shoulder, child crying, wondering to myself how much damage I am doing to my knees by constantly kneeling like this day in day out (I, afterall, want to be an active old boy in the years to come with my own knees still!), I ponder my future career as future vet…

5 minutes later, after many tears shed (including my internal crying!), which have now settled down to a quiet, exhausted grizzle, the cannula is in, medicine is entering the boy’s veins and I stand victorious.

Well, I say victorious – the boy and father stare at me like I am something out of a Stephen King movie. Rather than waiting for thanks, I quietly leave in search of my next victim…sorry – I mean patient.

And some coffee…

Wish me luck tonight.

Dr Nick

When you run out of ideas

So this week marks roughly the first two and half months as a junior doctor. Where did that go?! Oh hang on, I know – in hospital.

The last five days has been the usual melting pot of chaos, confusion and fatigue. Mind you, it’s funny how you get used to it so fast – the chaos, confusion and fatigue. So much so in fact that I even managed to get myself to two social engagements in the evenings…miracles do indeed happen it seems.

So what brought the chaos and confusion this week? Well since I was covering the urology team in the first half of the week – therefore seeing me constantly with patients genitalia in my hands as I try and pass a cathether into their bladder to relieve a urinary retention, I was not the happiest of chappies – as well lets be honest, that’s not how I like to spend my days! The second half of the week saw me back to my usual team – the breast and general surgery teams. This is much more in my comfort zone – less genitalia more appendicitis, pancreatitis, diverticulitis and cholecystitis (bascially anything hollow in the abdomen that can get inflammed and infected!). However the dream was soon shattered when my colleagues were struck down by illness and well, secretely planned annual leave – and as a result I found myself with 48 hours of being the only junior doctor on the team…and the on-call surgical house officer! That latter part basically means that when the senior doctors on-call need help seeing patients in accident and emergency I go down to A&E and see them for them…and as a result your “on-call bleep” can go off at any point of the day and shatter your plans for all your usual patients! And of course…the on-call bleep went off constantly…Lucky me!

There is however one patient I want to tell you about. She was, what I like to call, my “character building patient of the week”. This lady had been with us for some months how having had major abdominal surgery for a ruptured bit of bowel that had then given her sepsis (widespread infection throughout the body and blood). An elderly lady she never caused any problems and was always happy and smiling and helpful.

Until today.

On that dark dark day (ok, it was sunny outside but I am trying to build the suspense) I get a bleep from one of the ward nurses telling me that this particular patient is MEWSing (check last week’s blog if you have no idea what I’m referring to!) and that can I please come and assess her. Off I go. The conversation went a little like this:

Me: Hello, Mrs X, what’s the problem?

Patient: Oh it hurts everywhere!

Me: everywhere?

Patient: Yes everywhere!

Me: Can you be a little more specific? I can’t help you as well if we can’t narrow down, ‘everywhere’..

Patient: My chest! It’s a crushing pain!

Me [in my head]: Sh*t she’s having a heart attack

Patient: And my tummy is so tense and I can’t poo or pass wind!

Me [Again in my head]: Double sh*t she’d having a heart attack and has intestinal obstruction and possibly sepsis!!

Me: Does it hurt anywhere else

Patient: Oh my legs and my arms…

Me: So we are back to it hurting everywhere?!

Patient: Yes everywhere!

At this point, guys, I can tell you I am fast running out of ideas. Essentially I was stuck looking at a patient who may possibly be having a life threatening heart attack and abdominal sepsis OR just being a little dramatic. Fact is you have to think worse case scenario and so I proceeded to examine her fully, do an ECG, urine sample, abdominal x-ray, erect chest x-ray, arterial blood gas on her wrist, take bloods to see if she was indeed having a heart attack or infected (but, not actually taking any blood…), call the cardiologisys, my surgical team and the outreach team (a team of expert nurses who float around the hospital helping doctors with very unwell patients)! Oh and the best part was that she refused any kind of blood test or cannula. I mean it was so frustrating – I had a lady who need “access” i.e. a tube in her vein so we could give her emergency fluids and drugs if indeed this was a worse case scenario…and she was point blankly refusing it all.

I had truly run out of ideas.

And as with this job a lot of the time…you know what it turned out to be..

CONSTIPATION.

What a day….

Right all, have a great week and we’ll speak then.

Dr Nick

What is Health: The Community Membership?

Hi all,

So this is all very unorthodox isnt it…me..blogging mid-week!

I should explain myself. It is most likely a combination of exhaustion and declining brain function with euphoria at the fact that my 19 day stretch of hospitak shifts is coming to an end. However, I read an article in the British Medical Journal on the train this morning (well, I say reading but at 5.45 am I call it more like glazing over a blurred page as I try and stay awake long enough to get off at the right stop..) that just make me sit up and think….this is SO SO true.

And so, I wanted to share it with you. I hope the author doesnt mind me para-phrasing it but it here we go:

“What is health? Wendell Berry refers to health as membership. In other words, health is tied to our sense of connection to community. When disease disrupts the bonds of those connections, or requires that they are broken (as for the addict or victim of domestic violence), the doctor’s job is to ease and facilitate the patient’s transition. We are agents of change, from disease to health, from brokenness to a more connected, responsive and responsible whole.” (by Dr David Loxterkamp)

Forget the endless biomarkers of disease that distract us from our job as a doctor…

I, for one, want to be an agent for change – from disease to health.

That sits well with me and my soul.

Dr Nick

 

“Doctor…the patient is MEWSing”

This, ladies and gents, is one of the most common things I have heard this week. It is, actually the most common things I hear every week. So it begs the question…what does it all mean?

A “MEWSing” patient is essentially a potentially unwell patient. It serves as an indicator for all health care professionals that come into contact with that patient as to the status of their health. This is both for that very moment in time, and compared with the MEWS of the patient over the last few days.

So what a MEWS consist of?

MEWS: MEDICAL EARLY WARNING SCORE

  1. Respiratory Rate
  2. Body Temperature
  3. Blood Pressure
  4. Heart Rate
  5. Oxygen Saturation (and if supplemental oxygen is being given)
  6. Urine output (we want better than or equal to 30 millilitres of urine passed an hour)

When a MEWS score goes above 3 (it varies between hospitals) the nurses alert us, the doctors, to come and assess the patient for something is essentially not quite right with the patient. It may be that the patient has an early infection brewing – such as a chest infection, a post-operative complication and they are bleeding internally, or perhaps a reaction to a new medication or blood transfusion. Bottom line is the MEWS allows us to intervene early so that nothing else really nasty can take hold – such a sepsis – a widespread blood infection that can affect all organs and kill.

So, let me give you an example of this MEWS in action. I get a bleep on Tuesday and the nurse quite rightly says “you have a MEWSing patient on X ward – can you please review them?” So off I go and see them, putting down my skinny latte and golf clubs. The patient has a temperature (a pyrexia) and a fast heart rate (a tachycardia) and is recently out of surgey. They have a MEWS score of 5. In a situation like this your big concerns are a post-operative complication (bleeding, infection and so on) and – yes – potential sepsis! Doctors ALWAYS think sepsis for most situations. Why? Quite simply you do it because if you were to miss it and don’t treat quickly the chances of the patient surviving (if it was indeed sepsis) is rubbish. So with a MEWS of 5, and the devil on your shoulder whispering “sepsis!!”, you go a little onto autopilot and do the following: (1) clinically assess the patient i.e. listen to the chest and lungs, (2) perform a septic screen including taking blood from a vein in the arm, performing an arterial blood test from the pulsating artery in the wrist (to see if the body is acidotic), ordering a chest radiograph (to see if there is a chest infection), and testing the urine i.e. a ‘urine dip’. Basically what we are doing is looking for a source of infection.

Then, while all this is going on we try to ‘optimise’ our patient by making sure the body is coping alright. We essentially take the load of the body and so give intravenous fluids to maintain blood pressure and keep heart rate stable; start antibiotics to pre-empt an infection, pop a urinary catheter in (as we want to monitor both the fluid input and output and make sure they balance i.e. the patient is ‘euvolaemic’)…and then we wait for the results.

Often then we find out that the patient has a urine infection or chest infection (like hospital acquired pneumonia) and luckily the antibiotics we have started them on is enough to have them ship-shape in no time at all! However, when it goes bad…it goes very bad…

You see the scary times are when a patient has ‘septic shock’! This is essentially when the patient is so overcome with infection that their body’s blood vessels dilate (widen) so much that the blood pressure plummets and the heart rate shoots up! That is when the patient is very very sick. Organs get damaged as a result and the body goes down a slippery slope towards death. If I have even a sniff that this is happening, that is when it’s time to get the seniors involved – and often the patients are carted off to intensive care…

Right, as I am on day 14 of a 19 day straight run of shifts and having done a 10 hour shift and cycled 9 miles to and from work, I have worked up an appetite so I am going to leave it here for this week and say goodnight!

See you next week guys,

Dr Nick