Referring: “That patient looked at your Consultant – They should take over their care…”

Now I am writing this mid-week for one very good reason. I am on annual leave! Never two better works spoken (well ‘pay day’ is also nice..)! So on a Tuesday morning I sit here in my lounge, cup of tea in hand, cat asleep on the sofa, and BBC Breakfast talking about something I have no idea about.  Bliss. It certainly trumps the usual fight to a computer to update the patient list, finding out I’ve misplaced 4 patients and can’t find where they’ve been moved (hospitals love to play musical beds with patients when the day time doctors go home…), and that I already have a list of jobs as long as my arm before the shift has even officially started. Like I say, today, is bliss! But, dear reader (I say reader as I only think my readership extends to my mum currently), this is not why I am writing this today. Today I am writing to tell you about my biggest hurdle as a doctor.

Referrals.

They can just be SO awkward. I mean painfully awkward. And as a junior doctor, it is my role to do the referring.

So for those of you who don’t know about what a referral is, please let me explain. There are two types. The first is a simple referral where advice is sought.  Now a patient is under the care of a consultant in hospital. For example, a lady with a bowel cancer under a colorectal surgeon. If this lady then develops a heart problem, we then need to get some advice from the heart doctors – the cardiologists. This is a simple referral. The second type is permanent and about handing over care. For example, a patient comes in being looked after by the surgeons and then has their surgical problem fixed. However they are still unwell with some other medical problems. The consutlant surgeon would therefore want a medical doctor (not a surgical doctor) to officially take over their care i.e. a transfer of responsibilities.

It is this that I hate.

You see my consultant on his ward round will simply see a patient and then as he walks out away from the hospital bed state the patient is surgically fit and so “transfer to medics” to manage the ongoing medical issues. As I ink the words onto the notes page (I am carrying about 5 patient sets of notes by the way and can’t feel my arms anyway by now), they are blotted by the solitary tear shed from my eye as I realise I will be the one making that “transfer to medics”. Fast forward 20minutes and I sit at the ward desk, preparing to make the ‘transfer to medics’ phone call. This has a number of stages.

Number 1: Make sure you know what is going on with the patient. This is not always easy….

Number 2: Make sure you have your confident “No no we are completely done with this patient” voice ready

Number 3: Have an air-tight reason why you cannot possibly look after this patient anymore and they must take over

Number 4: Say a little prayer

So here we go. I am locked and loaded as they say in the movies. I make the call. Here is the reality of that call:

[Ring Ring]

Medical doctor: “Cardiology Reg”

Me [surgical doctor]: “Hi it’s Nick Knight, FY1 to Mr X the consultant surgeon”

Medical doctor: “And?”

Me: [awkward pause as I swear under my breath] “I’d like to discuss a surgical patient that we feel is fit for surgical discharge but has ongoing cardiology issues. We would be grateful if you could take over their care. May I give you some more details?”

Medical doctor proceeds to ask me 10 million questions, investigation results and things that I am not even sure I had even heard of – even in medical school.

Medical Doctor: “This is an innappropiate referral – I am NOT accepting. You clearly have no clue about this patient.”

Usually too you might get told how sh*t you are as well. So, with that wonderful, heart-warming exchange, I hang up the phone and move down the list to the 2nd of 5 referrals that my consultant has made me do.

Once again, I find myself wishing I had trained as a vet….

Moving on from this horrible scenario I want to share very quickly (as I have a very busy day of putting my feet up and soaking my annual leave joy) with you something called SBAR. SBAR is a communication tool that the NHS uses. I think it is pretty cool and to be honest could be used in many businesses and walks of life. Here’s what it stands for and a working example:

S – Situation

e.g. “Hi it’s Dr Nick Knight, I am the surgical F1 on call, I have a patient I’d like to discuss who I’m very concerned about”

B – Background

e.g. “Mr X is a 54 year old male smoker with a background of diabetes, who has presented with atypical sudden onset chest pain

A – Assessment

e.g. “He is tachycardic with a heart rate of 110, and an ECG showing ST-segment elevation in leads V1 and V2”

R – Recommendation

e.g. “I believe he is having an atypical presentation of a myocardial infarction and have started him on acute coronary syndrome protocol but would like some more recommendations from you on how to further manage this patient?”

A great tool – one we could all use to promote continuity of communication.

Right, my tea needs topping up and I am sure their is a Christmas movie I NEED to watch on television…

Have a great week all!

Dr Nick

“OK, Dr Knight, you can close”

The 5 inch gaping abdominal surgeons incision that is.

Welcome, ladies and gentlemen to life as a junior doctor in an operating theatre.

Life within theatre is a bizzare melting pot of sterile, protocol-driven activites, James Blunt music and discussion over whether I should shave off my Movemeber beard. As someone who is a self-confessed NON-SURGEON, I must admit, I have kind of enjoyed this week. You see in a rare twist of events I was taken off the wards (not for something I had done!) and placed in theatre, as they were short of more senior doctors, to assist the Consultant Surgeon.

Consultants Surgeons by the way are the most feared and reveared people in the NHS. After their medical secretaries that is.

So there I am standing in my ill-fitting scrubs feeling as though my buttocks and thighs have been cling-film wrapped by the blue scrub material (they only had small mens scrub trousers left). I only realised the stupidity of the ankle swinger look later that day on the post-op ward round. Anyway, there I am 8.55am in theatre surrounded by 4 or 5 (I couldnt tell as they all run around so quickly)  theatre staff laying out sterile operating equipment and preparing the patient who lay anaethetised with cool drugs that sadly they don’t let you play with as a junior doctor.

“Shit”.

This is the thought that came to mind as the Consutlant Surgeon bellows “Well then Knight – get scrubbed”.

Getting scrubbed is a very formulaic procees of making yourself sterile.

No, not in that sense…

In the sense that I have to wash my hands and arms for 5 minutes in a set pattern that allows the water and bugs that may be living on my skin to run away from my hands. I then pat them dry from the hand to the elbow (you don’t want to take dirt from you elbow to your hand but we move any remaining dirt away from the hands). Then I stare at the opened scrub pack (by helpful theatre staff) which contains my scrub gown and gloves. I should add at this point that I am in a mask and scrub hat to avoid coughing over anyone.  You slide into the gown and gloves (without touching the outside of anything!) and there you go – you are scrubbed and ready to operate.

That process takes me 10 minutes. A senior surgeon does it in 3 minutes (and makes you feel a bit slow and clumbsy in the process). The seriousness in being scrubbed is this. If I brush my gown on something NOT sterile i.e. a table or an non-scrubbed person….you DE-SCRUB i.e. remove everything and repeat the process. This is how we cut down on peri-operative infections.

Fast forward 30 minutes, and I leaning over the first patient with my Consultant Surgeon on the opposite side of the table. We are both closely examining this man’s groin area which we have happily cut open with a 5 cm slice thanks to an exsquisetley sharp surgeons scalpel. The consutlant comments that the transversalis fascia has a weakness causing the direct hernia to the medial aspect of the inferior epigastric artery. Now yes, I know what this means and undertsand the process and required actions to correct it (a mesh inserted into the inguinal canal sutured in place). However, staring down at this open cavity, I may as well have gotten out a magic eye as it all looked the same – gunk. A trained, experience surgeons eye is beyond impressive. As such I just noded and said a few words that suggest I agree and support his opinion. HA! As if he needs my validation!!

Fast forward another 30 minutes during which time I have been holding two langenberg retractors constantly. My shoulders are really burning at this point, my back killing owing to the 6 inch height difference between myself and my Consultant Surgeon and hence the operating table being well, basically on the ground, and then he says “Ok – you can close.”

The moment I have been waiting for. Time to shine!

“3/0 Vicyl, straight needle” I command with confidence to the scrub nurse who hands the surgeons their operating equipment. I stare at the surgeon-inflicted gaping hole. I pause – not in a dramatic, season finale of Friends way, but in a way that makes me consider myself very lucky I was able to do something so cool. Post non-dramatic pause, I put in the first stitch.

I breathe a sigh of relief – the stitch didnt kill the patient. Result.

Many stitches later, I have “closed the patient” (well, plus a few steri-strips as I left a bit of a gap in one part of the wound..).

I step away from the patient and look at the consultant. I feel proud of my achievement. A sense of anticipation in me builds up with the eye-contact developing between my consultant and I. Is he going to tell me that I did a good job?! I wait. The silence and locking eyes makes me begin to feel a little awkward..

“Go and consent the next patient”. Ah. Not quite the reaction I was hoping for.

As I leave and walk into the main hospital in my scrubs off to consent the next patient, I catch the eye of a few hospital visitors. I can’t help but smile for today my job felt pretty cool….

I’ll catch up with you all next week.

Nick

The Burden of A Public Conscience

So this week my blog is admittedly a few days late. My excuse? A heavy night out on Saturday. As a 30 year old in London I have fast realised that I am no longer 21. In fact I am no longer 25. My days of playing Peter Pan are over and as such it takes me 72 hrs to recover from any excess of alcohol. And now that my faculties have returned, I wanted to share with you my lesson as a doctor this week…

It’s fair to say that this one crept up on my unsuspectingly. I was typically leaving work late and in a semi-irritated state and a comment a patient had made about waiting for his cannula (I was at the bedside of a palliatve patient speaking with their family and trying to give them answers to some very hard but necessary questions they had). It was raining, dark and cold. It is November and London afterall. I longed for my bed. As my mind drifted towards where I had hidden my hot-water bottle (hidden, for fear of my housemates deeming me uncool for being a guy with one!), I was presented in the darkeness by a young woman dragging a man in a wheelchair out of the middle of the road.

Now we have all done the “cross the road when we see a bunch of dodgey youngsters” move before when walking down the road. Shamefully my initial reaction was the same. I thought to myself, she looks strong, and seems to have things in hand…and my train was in the next 5mins – and as such any intervention could delay my return home to food, a shower, and of course…this elusive hotwater bottle. But then I was flooded with this odd sensation. I felt a melting pot of guilt, duty as a doctor, and general desire to be helpful to this young lady (who was, I might add, quite attractive once I walked closer).

So I deviated from my original plan and approached her, and in my best superhero voice proclaimed:

“Can I help? I’m a doctor”

(note – I omitted the fact that I use this term ‘doctor’ loosely meaning that if he needs a cannula, blood taking or a fax send then I am indeed your man…)

The lady explained she was on the phone to the paramedics. I looked down at her prize that she had dragged from the road. It was a middle aged man, with one leg, looking dishevelled and well, comatose. I leaned in closer, popping out my ear phones so the comatose chap and the attractive young lady could both enjoy the melodic tunes of Jack Johnson, and had a look at this man.

Shit, he looked dead.

A quick feel of his pulse revealed he was indeed not dead and a smell of him revealed he had probably had a few too many to drink. I am not sure where his other leg went but lets assume he had not had it for a while. Having confirmed his name and date of birth I asked to have the phone and speak to the paramedics. I triumphantly explained my status as a doctor before indeed realising I have very little to add to this picture except that he was not dead, had one leg and was likely just drunk. The attractive girl at least look impressed. Maybe I should have tried to but a cannula in him too – she would have been blown away truly then!

For the next five minutes I tried to look busy with the homeless man – principally by holding his head up so he didnt vomit, aspirate (i.e. swallow his vomit into his lungs, develop subsequent aspiration pneumonia and potentially die) while he decided to come to and call me all the colourful names under the sun. I thought to myself – I get this all day at work – why the hell have I volunteered for it outside as well!

Finally, just as I hear the distant rumble of my train passing by, the paramedic turns up. I swear these guys are getting bigger – I’m 6’2 and he made me look tiny! Turns out are one-legged wheel chair pirate was a regular attendee with a sad background. I felt for this chap. Alcohol addiction can destroy a person’s life – and those around them that love them. I feel very strongly about this for a number of reasons that I don’t wish to divulge. Why bring this up – although I talk of this story lightly as a means to highlight that moral tug we feel as doctors, make no mistake – alcoholism can send anyone into a spiral of poor health, social desolation and death. Don’t judge them but instead show them kindess, compassion and neutrality not judgement. You will be a better person for it.

As for me, I said my fairwells to the attractive lady, the one legged drunk (who promptly told me to “go and f*ck myself” – I declined), and the giant paramedic, and strolled to the station feeling a little better about myself. Next time, I won’t even consider crossing the road – I am doctor and I have a moral obligation to help – even if I dont always feel like it.

Oh, and I never did find the hot water bottle.

See you next week,

Dr Nick