Death’s Diving Board (oh, and figure skating…)

Today is going to be a short and sweet entry as, well, I’m pretty exhausted.

This week I have seen two patients leave the Intensive Care Unit that I thought perhaps never would. Both were our resident guests for 41 days and 39 days respectively. Both had multiple organ issues – and indeed failures – that stacked the odds very much against them ever leaving the unit alive. Both suffered cardiac events (heart attacks, basically) and one was intubated and ventilated for well over 35 days. In fact it was only day 40 that this patient even had the ability to speak (tubes down your throat do tend to hinder this capacity of course….). It is a true testament to themselves, the ability of the human body and all of its marvelled physiology and biochemistry to work to maintain an internal environment compatible with survival…to fight for that homeostasis. It is also testament to the teams of nurses, health care assistants, chest physiotherapists, dieticians, imaging specialists like the echo-cardiographer technicians and radiologists and finally the doctors (I am sure there are many others too) that work to keep these patients alive in the first place and secondly try and get them to some pre-morbid function that will allow them to continue on with their lives with some degree of independence. I count myself as the very bottom of this list (after-all a few cannulas and chasing of scan results hardly impacted that much) – but all the same, I am proud to be at least a very small part of a very big and experienced multi-disciplinary team!

This is amazing because these patients, and many, I am sure before them, before my life as a doctor began, have stood on what I have decided to call “death’s diving board”. These patients have stood on the end Death’s diving board, toes curled around the edge, head pointed down and hands outstretched, ready to stop living. The decisions, interventions, desire, physiology and timing will decide whether they make the leap and don’t come back…or step away from the edge and head back down the ladder to terra firma. So this week I got to see two patients come down that ladder and go from being intubated and ventilated, lifeless bodies with machines surrounding them acting as their organ support – to patients who are eating and drinking, joking with me and telling me about their lives and what they still want to do with them. Sadly for every one that steps away from the end of the board, and new one is already climbing up the ladder to take their turn at peering over.

And you know, amongst all the tiredness, long days, and self-doubt about whether you (I mean me, obviously) should even be in hospital with the title of doctor, it is the week’s like last week and results like that which make me think maybe, just maybe, it is worth it.

Have a great week everyone and hope the Sochi Winter Olympics have inspired you! What people do with their bodies is truly amazing – and no truer display that than over the last 18 days! My personal favourite which came much as a surprise to me as to anyone was the figure skating….how just how they manage to effortlessly float across the ice, jumping and spinning is just, well, you cannot do anything but just marvel at it. I know I did. Ok, and yes, they were very attractive too…

See you next week!

Dr Nick

Early Morning Thuds

Now being a doctor means that no day is rarely ever the same in hospital. You get different patients on your ward round, emergencies for your patients crop up (usually around 5 or 6 pm – just as you are planning your swift exit from hospital), and you get the opportunity to do things that you never anticipated that day (from the fun stuff like putting in a chest drain to the less fun stuff like manual faecal evacuations…I’ll let you sketch the mental image of that latter task….!).

What you don’t often anticipate is when you have to deal with other doctors random patients. Usually this is a case of wrong person, wrong place, wrong time…

So there I was having snuck onto the post-operative surgery ward at 7.05am – all the patients fast asleep, the daytime nurses in the office have a verbal handover of the patients from the night nurses (no, not the cold medicine…) and the night shift doctors likely tucked up in the mess dreaming of the bleep well, not bleeping. In case you’re thinking why was I a) in work so early and b) on a surgical ward when I am currently working in the intensive care unit, I was in fact collecting data from surgical patients notes for an audit (i.e. a look at hospital protocols) on peri-operative (i.e. before, during and after) temperature recording.

I have my back to the ward bays as I sift through notes (still, I might add, dreaming of my first coffee of the day) when I hear the dreaded shuffle of an early-riser patient. I turn the pages of the notes I am looking at that fraction quieter in a vain hope not to draw eye contact with the patient or invite a question about her operation (all patients seem to think every doctor will know about THEIR operation for some reason). Luckily I escape the question and the eye contact.

The shuffling behind me continues….

“Oh, this patient didn’t have his temperature measured…” I muse to myself as I stare at the notes…

THUD.

I look up from the notes staring at the wall, simultaneously thinking “that is NEVER a good sound in hospital”…

I peer over my shoulder to see a clear corridor…but the THUD came from somewhere. Hang on, where’s my ‘shuffler’? As I peer over the nurses’ station desk I discover the previously shuffling patient, well, not shuffling.

In fact she wasn’t doing much of anything. She was out cold on the ward floor.

At 7.07am my audit data collection comes to an end and a full 53 minutes early I have to work as a doctor…

“I want some help at the nurses station immediately please”, I try to say in a not too annoyed tone.

I walk to the patient (rushing in medicine does nothing and only leads to mistakes) and check she is breathing and has a pulse. She does. That is good. I hate death certificates. I grab her legs and raise them, just as a two helpful staff members stroll over.

“This patient has just collapsed, I don’t know who she is but I want you to 1. Connect up a 15L high flow 100% oxygen to her via a face mask from a portable canister 2. Connect up some remote monitoring for heart rate, blood pressure, oxygen saturations 3. Get a pillow under her head 4. Get me her notes please and 5. Get me a coffee.”

I’m kidding about the last request, obviously…though I did really want one!

They beaver about and get all these bits done very efficiently. I stand there holding her legs up still – my mind thinking that this is in all likely a syncopal collapse (a faint) post-operatively. I ran through the resus protocol A, B, C, D, E:

A: Airway – patent (she was starting to moan which tells me her airway is open)

B: Breathing – respiratory rate 15, oxygen saturations 100% on 15L of high flow oxygen

C: Circulation – heart rate 80bpm, blood pressure 88/55, capillary refill time <2sec

D: Disability – pupils equal round and reactive to light and accommodation, all limbs moving.…AH! I haven’t asked for a blood sugar…

 “Blood sugar pleases guys after you’ve done the first 4 things”…

Blood sugar was normal.

E: Everything else – no obvious cuts or bruises from her fall (but you can’t rule out a surgical bleed)

While someone takes over the patient’s legs I have a quick look through the patient’s notes – 38 year old female, day 1 post gynaecological operation, hasn’t had much intravenous fluids since the operation, hasn’t taken any pain relief (and the nurses verbally she hasn’t been drinking much fluid orally either…).

So let’s recap:

A dehydrated, post-operated female patient with a low blood pressure who decided to go for a stroll….

This is most likely a syncopal episode.

So, with all that in mind, we get this lady back into bed (with regular 30mins observations, some intravenous fluids to pick up the blood pressure, some pain relief drugs and some biscuits). It’s still 20 minutes until I am supposed to be working as a doctor but I call the surgical team that operated on this patient and handover what has happened.

7.55am….

I sigh, still 5 minutes until I’m meant to be ‘working’…Hmmm I wonder if the NHS would give this unofficial doctor time I have just engaged in as time off in lieu…?

I know, that’s what I thought to…unlikely!

Like I said at the start, no day is the same and something tells me that similar encounters with patients will pepper the years to come…

Have a great week everyone.

Dr Nick

Suicide

There are fewer sadder experiences as a doctor than meeting someone who has tried to take their own life. It is not a sadness for me at witnessing someone in hospital with that history but a sadness for the person who feels that their life is so hopeless that that are better off beyond it. Working in intensive care has opened my eyes to the struggles that many people feel in their lives – struggles that drive them to attempt suicide. On a weekly basis, you see, I walk into the intensive care unit in the morning (because these attempts usually occur at night – supported by alcohol) to find a new young person intubated and ventilated having taken a massive drug overdose or having tried to hang themselves.

You realise how precious life is when you see patients, critically ill from some infection, trauma or disease. But seeing someone who deliberately challenges their life is, for some reason, even harder. Perhaps it has to do with control. I say this because when you think about it, you can’t help getting sick sometimes – and as a result as a doctor we treat the cause as best we can. It is a tangible source such as a blood infection, chest pneumonia or leg fracture for example. You know the cause. You stop it.

The drive to suicide, however, is often not tangible.

That scares me as a junior doctor. How do you treat what you cannot see? How do you manage people who are so unwell that they look to suicide as a solution? I think that it is generally accepted that many doctors find these illnesses hard to deal with for this very reason. But we must. We must find a way to help them, treat them and block perhaps what is the greatest challenge of all – stopping them trying again. Having met people in the intensive care unit for whom this is their sixth attempt in the past year, you realise that this is not always possible. We cannot after-all control what choices a person makes.

We can however give them all the support, treatment, understanding, and kindness that we in modern medicine and in a modern society have to offer.

Dr Nick

10,000 hours to becoming an expert doctor?

This week I want to talk about something a little different – expertise.

Now as a junior doctor I am constantly and acutely aware of how much I have to learn…and indeed how little I actually know. One of the goals of going into work each day, whether it be in the intensive care unit or medical wards, is not only to care for patients but to learn. This learning is critical to my daily life as a junior doctor for without I simply won’t progress – I won’t become an expert doctor. Now I don’t care what people tell you – everyone wishes to be good at their jobs for it not only makes their lives better and more rewarding but it also makes life easier. I, for example, watch with envy as the senior registrars and consultants on the intensive care unit diagnose and manage acutely unwell patients with multiple organ failures and on the brink of death with such calm and ease.

Yes, I am sure the cogs are turning but they are turning in a well-oiled, slick, calm and experienced head!

That is how I would like to be. That is what I am working towards every day. As such, I consider that no experience – irrespective of the trauma it causes me – as a doctor – is a bad one. As long as I learn from it, I will be better for it.

Life is the same.

Which brings me to the book I am reading at the moment – The Sports Gene. This is a book that tries to unravel the evidence as to what makes an elite athlete, well, an elite athlete. Is it nature? Is it nuture? Well, in this regard it holds its hands up early on and says it is obviously both (we all know that) but how much of one versus the other? It is a great read and has already set my mind in over drive at some of the statements it has made, because I wonder – does it apply to medicine?

Let me explain two of the key points. Firstly there is this idea of innate ‘hardware’ versus learned ‘software’. The innate hardware is our genes – the nature part of the equation if you like – and the very framework of our biological basis. The learned software is our learned skills – the nuture part of the equation. Now comes the interesting part. There was an article published in 1993 in the journal Psychological Review called “The Role of Deliberate Practice in the Acquisition of Expert Performance”. The takeaway message was that despite innate hardware within us all, that it the learned software that produces expertise. Now, very (I mean VERY) loosely the number of 10,000 hours of deliberate practice to yield expertise was quoted and has since formed the basis of the concept:

It takes 10,000 hours of practice to become an expert.

Hello…..!

So this got me thinking. Does after 10,000 hours of studying medical theory and being on the hospital wards, launch me into the realm of being an expert? How long will it take before I am able to say this…Interestingly, and please do bear in mind this has very little scientific rigor (apart from a scrap of paper and a pen whose ink ran out half way through my calculation), the book and the journal article say these 10,000 hours of deliberate practice spread out roughly over a 10 year period i.e. 1,000 hours of deliberate practice per year. And….

….from the medical school to consultant level is also roughly 10 years.

Perhaps, without even realising it the very pathway that I am on as a junior doctor, has coincidently aligned itself with what researchers are proposing. Personally I like this theory as I can very confidently tell you that my innate hardware is nothing exciting – I have a brain that forgets a lot of things and struggles at maths big time, a body that has kept me healthy and active but by no means a super athlete! – and  you know,  I am happy with this arrangement. The software in me though, what I have learned over the years, is what is making me a safe doctor – and hopefully too one day, an expert.

Well, I say one day…I mean 7 years…

Better put the kettle on then! As Robert Hasting suggested in his poem ‘The Station’, it is afterall, all about the journey…

See you next week.

Dr Nick