Junior Doctor Survival vs. Island Survival

FOREWORD:

Survival can be defined as the struggle to remain living. In 1869 Charles Darwin used the phrase “survival of the fittest” in his book The Origin of The Species. This is not a statement of the purely physical status of the species but, as he later eluded, that it was the ability to be “better designed for the local, immediate environment”. The human body is physiologically adapted to survive in many environements. Of the many physiological systems that function as parts of the human body, they indeed react to this “local, immediate environment”, that Darwin talked about. Although physiological function of the human body is not, as suggested, the ONLY factor for survival, it is one of the most important. The reason for this is, without this physiological function, the body would fail and death would be inevitable.

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Life as a junior doctor is crammed full of physiological and mental challenges for the body and mind. Now, since I have had the pleasure of creating that short online video for TV show The Island with Bear Grylls on how “island life takes its toll on the men”, I’ve been thinking – what, if any, are the comparisons between surviving on a deserted tropical island with only the sort of scarce food that has to be caught and no easy access to drinkable water – versus a 15 hour shift on a particularly traumatic day as a junior doctor. Just a bit of fun really, but lets see what we come up with, shall we? As this is a massive topic that could cover everything from temperature regulation, metabolism, inurgy, illness etc, I decided, for your own sanity, that we’d focus on the the following three key aspects – energy expenditure, fluid balance and stress.

But before we dive into these three, I wanted to show you something that is pretty interesting. It’s called Maslow’s Heirachy of Needs. It suggests what motivates people in life. Now, although designed way back in 1943 it still rings true today (as long as they add in Facebook Status Updates of course…) It’s represented as a pyramind, with the more important aspects of life at the broader base and the less important aspects moving upwards from this towards the apex. How do your own life needs fit in to this?

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Right, down to our three comparisons! In a healthy physiological state, free of disease, illness or trauma, the human body prefers a neutral energy balance. This can occur when energy supply from foods are matched to the metabolic demands of the human body. Now this energy is usually supplied in balance by the three main macronutrients: carbohydrates i.e. sugars (45-55%), fats (20-35%), and proteins (10-35%) – and will vary between individuals demanding on their requirements (for example, if your are a hulking bodybuilder you will probably have you diet loaded with protein..). On the island the natural energy balance is clearly swung in favour of an energy imbalance towards insufficient calorie intake. As a result their bodies begin to consume first the sugars and then the fats that exists within their bodies as fuel. In comparison, on my worst shifts as a junior doctor, I will have had breakfast at 5.45am….and not have anything to eat until maybe 10pm that night! Now I can all hear you crying out “HOW IS THIS POSSIBLE!!” – but very sadly it is – there are days were the treadmill of patients, urgent jobs, emergencies and pure unbridled medical chaos just does not end! As a result, my body very quickly uses up the energy from the food I ingested at 5.45am (thank God for Weetabix), uses up the carbodydrates circulating in my blood, and starts to call on the energy reserves that my body has. Firstly this will be the carbodydrates stored as glycogen (mainly in my liver and some in my muscles), and then onto using the fat that helps keep our trousers not requiring that belt! Luckily for me when I get home at 10pm I get to sit down to a nice steak, pint of milk, a banana, and all the fresh water I want. For the men on the island, they don’t have that luxury and so their body flips slowly but surely into starvation mode, peppered with a few paultry meals of snails and fish – and of course the odd, poor, crococidle. May he rest in peace.

Of course that energy from food doesnt just fuel all the metabolic processes within muscles and organs – it also fuels the brain. On the island the men struggle to think, to plan complex tasks and become less and less mentally effective at surviving. Although due to a number of factors, a huge component will be the fact that their brains simply don’t have enough fuel. You see the brain loves carbohydrates – it can use them nicely as a fuel. It dislikes fats because fats struggle to get from our blood and into the brain where it could be used as fuel. In modern society that explains two things: Firstly, why when we grab something sugary to eat we get the mental alertness boost BUT then swiftly followed by the crash (as the carbohydrates are used up so quickly) – and then hence why we immediately grab something sugary again ; And secondly why we feel mentally dull sometimes through our mass consumption of high fat diets in Western society – there is just little fuel for the brain in these diets. On the island of course they are living to survive and so the brain will be sadly lacking in good usuable energy. That is, until the body learns to adapt and adjust in its survival mode that thanks to modern living has laid dorment for year after year. This adaptation includes the manufacturing of ketone bodies – a very special alternative fuel that in survival makes the different between surviving for days or weeks. During my hectic 15 hour largely food-free day having my brain become less effective is clearly dangerous. I mean, that said, it wasnt that effective to start with! And now it’s really ineffective! I find that as my brain struggles to find an fuel, my decision making processes to plan treatments of a patient slows down, is more prone to errors, and my reaction time to perform practical tasks like putting in a cannula or assisting with a cardiac arrest dips massively. Trust me, that sort of mental crash hits you like Serena Williams on Wimbledon Finals Day. That’s why I now always always walk around with food in my scrub pockets – it seems, rather amusingly, that the status of my belly fullness, is pretty important to patient care!

So we come to water. In the words of the Rime of The Ancient Mariner, for the island men it is “water, water, everywhere; nor a drop to drink”. They are having to struggle with transporting, boiling and distilling a lovely pool of stagnant water on a daily basis – and on a mass scale. That means, forgaging for plenty of dry wood to get the fire going all day, transporting gallons of water for the 13 mens huge daily water needs and having to risk infection and gastrointesinal illness causing diarrhoea and vomiting – making them even more dehydrated. For me as a junior doctor, it’s more like “water, water, everywhere; but there’s no time to have a drop to drink”. Again, I hear you scream HOW IS THAT POSSIBLE! On the bad shift days it really can be. In fact, I have gone a good 12 hours without a drink, while running around the hospital like a headless chicken. This is very irresponsible of me – and indeed dangerous – my lesson was swiftly learned let’s say! Now water, being the largest single component in the body at 60% of body weight (approximately 42 L), is unsuprisingly very very important. Water keeps us a alive, and unlike food, where we have been reported to survive for upwards of sixty days, without a drinkable water source, we would die within 3 days give or take the specifics of the situation. When the body starts to run low on water, it works to conserve it. The body has a marvelous system of hormones (known as the renin-angiotensin-aldosterone system or RAAS….yes yes, I know, big yawn…) and nervous system activaton (mainly sympathetic) that works to retain water. The result? Well, as you could see on the island, the mens urine output reduces in volume and turns that wonderfully dark colour as it becomes more concentrated via the work of the kidneys to retain fluid. To top it all off, you will of course pee much less frequently as well. Believe it or not, this is exactly what happens to me by the end of my really horrific days. I can recall leaving work at 10pm at night, and realising I hadnt actually had a pee all day. Thinking, “Oh I better have one”, I go to have a one….not a drop. Dry as a bone. My body was a prune, desperately holding onto water. I have even heard of junior doctors developing acute kidney injury (I am not going to bore you with the details on this occasion) as a result of being so dehydrated. This is something that if left untreated can lead you down a slippery slope to death.

And no, I have not attempted to drink my own urine to survive on a particularly bad shift!

Ok team, I’m realising that I am rambling on for far too long, and you all have better things to do with your time, so I am going to talk about one last aspect: STRESS. Stress is awesome. It prepares you for life – so be thankful for it. Now the physiological response to stress is complex, having three main stages. Stage 1 is the alarm reaction – or the ‘flight or flight’ to you or I; Stage 2 is the resistance reaction; and Stage 3 is exhaustion. For the general public, it is unlikley that we will enter stage 3 for this is very sadly reserved for those that experience prolonged chronic stress, just as the horrors of prolonged combat stress in war day in and day out for an entire tour, and so on. As such I won’t touch on that. But stage 1 we have ALL experienced – whether it be that first date, exam, or just seeing that massive spider out of the corner of your eye. I have ticked all those three boxes! It is essentially a complex set of reactions  triggered from a part of the brain called the hypothalamus that stimulates your nervous system and adrenal glands. It all results, almost immediately in more energy release (as you will need it to escape) and more oxygen (supplied via you breathing harder and faster) in preparation for ‘action’. Stage 2 of the stress response is essentially the ‘hormonal back up’ of stage 1. Hormones such as cortisol, your ‘stress hormone’, are released to help bolster all the fast initiating nervous system activities that took place in Stage 1. Now on the island the men are constantly stressed. They have the stress of: meeting 12 other strangers, not being eaten by crocs, finding food, finding water, social in-fighting, being home-sick and so on. Their survival situation screams stress. If there was a reciped  for stress – The Island with Bear Grylls is it. And, unfortunately, it will be largely constant for them. This will sadly compound all their other needs for food and for water, as the stress response will increase the consumption of energy and water – and hence the replacement for them. In comparison, I am on the hospital wards. Hmmm, stressful? Yep. Hungry? Yep. Thirsty? Yep. Social in-fighting? Definitely! So my shift sees me in a stressful place. I suppose their is a different stressor as well – looking after people. I can tell you, although (some) doctors may waltz around looking cool as a cucumber, they are all experiencing some degree of stress that comes with looking after others. What if you miss something in the diagnosis? What if you make a mistake in treatment? Someone could die. Similarly on the island, by not pulling your weight, one islander could put the others survival in jeopardy. So stress is shared most definitely. But it’s all relative right? I mean, I am now less stressed than I was 11 months ago. I have grown in confidence, experience and awareness – my stress is therefore more a low lying background noise rather than in my face. For the men of the island, as they gain further control, experience and team-work the stress, although not removed, is controlled.

Right, let’s call it a day here. I need to get a coffee anyway. So I hope that was interesting for you. I am sure too that in your own lives you will have experienced similar episodes of food deprivation, water deprivation and stress, and can relate to some of this personally. I’d like to add too that I can assure you nowadays I make sure I drink plenty, eat healthily and make time for my own health. Being a doctor means I have to look after my own health as much as my patients – a dear (and clearly wise!) friend reminded me of that fact. So next time you watch The Island with Bear Grylls, just ask yourself the question – how do you survive?

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Answer – your human body – the greatest machine on earth with enough life, death, adventure and struggle going on under your skin’s surface to rival any Hollywood Blockbuster…

Dr Nick Knight

 

 

 

 

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Top Twenty Unpredictable Moments as a Junior Doctor!

I hope you all are enjoying the pure joy of a Bank Holiday weekend – I know I am! As I sit here on the balcony, digesting last night’s film fest of the Hunger Games 1 – and 2, I started wondering about all the unforseen things that have happened to me in the last 10 months as a junior doctor. Afterall I doubt Catniss Evergreen ever expected her life would take such an odd turn…
 
So, with that in mind, here are my TOP 20 UNEXPECTED EVENTS of my juior doctor year:
 
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1. Being taught mad yo-yo skills by the 10 year old niece of a patient in the final hour of a 15 hour shift
2. Describing to a Consultant Radiologist what type of fruit, the metal object stuck up a patient’s bum, is most similar to..
3. Relationship counselling between patients and their significant others (Jeremy Kyle eat your heart out)
4. Scrubbing a patient’s (removed) dentures on my ward round and being barked at by the patient that I “missed a bit”
5. Arguing with a vicar about the management of urinary tract infections
6. Having my Otis Redding’s “Dock O The Bay” ringtone awkwardly play loudly in my scrubs pocket, during surgery, for 2 minutes..
7. Turning down a marriage proposal by a 90 year old patient….then being offered her 30 year old granddaughter’s hand instead!
8. Discovering I’d broken a patient’s ribs during a cardiac arrest when I delivered (effective) chest compressions
9. Explaining to the patient that I am not a male nurse despite my ‘apparently’ small, gentile hands!
10. Explaining to the nursing staff that it’s the Nivea for Men moisturiser that keeps me looking younger than my actual years!
11. Having to explain why I have 3 needles in my bag on a bag search at the 02 arena (when I came straight from work for a gig)
12. Listening to HUGE psychotic patient describe how he pleasures a woman, while holding his penis, as I try and catheterise him
13. Nearly explaining to a girl I took out that I had been exposed to a contangious disease at work and she needs prophylaxis!
14. Have projectile faeces lightly speckle my bottom lip during a flatus tube insertion (that’s a tube up the bottom)
15. Having a vet tell me “oh so you can only deal with ONE species, can you” at a party. So I danced with his girlfriend.
16. Discovering razor blades under the bandages of a patient in intensive care that they had hidden there to harm herself.
17. Using my ‘doctor title’ as a chat up line in a pure moment of madness and I hang my head in shame for it every day!
18. Being threatened to “be taken to the papers” by a patient’s relative for not doing what they demanded
19. Having three AMAZING anaesthetic consultants trying to set me up with a waitress on a team night out
20. Having to turn away to from a patient who made me cry – a 90 year old gentleman just been told he had inoperable cancer and his response “Thank you Doctor – well – I’ve had a very good life, survived Bomber Command in the war, had a wonderful family life and so if you don’t mind, I’ll let myself have a lovely weekend with my grandkids before I tell the family.” Utterly Humbling and makes me well-up even now thinking about it. An example of a true gentleman.
 
I can only imagine what the next twenty will be….
 
Dr Nick

Sniff.

It begins with that unnerving feeling that something “just isn’t right”. The flight of stairs that you normal charge up in the morning, fuelled with caffiene and Hugo Boss For Men aftershave, takes a few more breaths than usual. You struggle with with zip on your bag, which normally glides open in one super-cool ‘swoosh’, and you find yourself getting annoyed. But – it is SO early in the morning to be annoyed – it usually takes AT LEAST until after lunch for that to begin. 

“Morning, mate” echoes from the corridor. You go to respond but find the obligatory insidious frog lurking in your throat. It takes a second to clear before the reminants of the ‘croak’ pepper your “Morning, bud” in reply. You shrug it off. It was probably down to the fact that you were ‘mouth breathing’ more last night as you went to bed and you’ve just dried out your throat.

But what WAS wrong with your nose then? Why the mouth breathing?

As you continue pacing towards the wards, leaving a trail of probably too strong Hugo Boss, you take that deep, airating sniff in through the nose – all designed to oxygenate the body and mind, swirl into the sinuses, and prepare man for the day ahead.

Except there was no airation, no priming, no swirling. Your heart rate speeds up and you start to panic.

The inspiration, naturally followed by the expiration of breath (apart from those unlucky few for whom it was their last), is delivered with a side of of coughing, sneezing and the first miniscule trickle from your nose.

You stop dead in your tracks. Your eyes glaze over. The b*stard has got me. Again.

I have Man-Flu.

From then on it is a non-stop assault. The slow-motion car crash that you know is coming takes hold of your body. But you know this old adversary well. It is not the first time you have met. Back in the Summer of 2013 it caught you just before your birthday and you vowed never to let it strike again. Oh Berocca, yourabundance of tasty multi-vitamins, how you have let me down.

You take a pit stop in the patient toliets just before the ward – now, technically being a patient yourself – and inspect the damage. It is not good ladies and gentlemen. Your eyes are that of a 16 year old boy just being dumped by his 18 year old cheerleader girlfriend – watery, filled with pain and sorrow at what could have been ‘that Friday night’, your nose a mess of redness that glows dimly against the NHS ‘energy saving lightbulb’, and the slow but steady stream from your nostrils reveals itself like a lava flow inbetween every inspiratory sniff in.

It is growing stronger by the minute. This must be a super strain of Man Flu.

As you lean against the toilet cublicle wall, being mindful to avoid contaminating anything now that you are infected, you decide it is time. Grabbing a handful of the paper thin tissues you ready yourself like an expectant mother in child-birth – except this will not be such a pleasant delivery,  you ponder. You place them to your nose, wincing as the red-raw skin is punished by the NHS quality tissue paper, and you blow.

WHERE THE HELL DID THAT ALL COME FROM?!

You stare in amazement and disbelief at what has been hiding in your nose all morning – half expecting it to scurry off and hide. What’s more is since you know that this is man-flu – there will be more up there. You grab another handful of tissues, mindful of the fact that you have now been in the toilet for some time and may be rousing the suspicion of security. You allow yourself a cough as the true wet gravelly nature of it surfaces now that you have discovered its presence. You blow again. The eyes water. The legs weaken and you get your first shiver. Oh man flu you taker of all things good!

You look in the mirror once again. The car crash is truly in full affect. How could it take hold so quickly?! A uncontrolled tear from your watering eyes plummets south over your cheek and falls kamakazi-like towards the ground. You wonder if your old friends in the intensive care unit would allow you a bed for the day – and perhaps, intubate and ventilate you to help you get through the worst of it. But you know you can’t – you know that the risk of spreading man-flu around the ITU is, well, just too great.

As you push on with your day it is a melting pot of sympathy for mistaken crying, sneezing quietly, patients avoiding you and attempting (and failing) to stem the tsunami from your nose.

Man Flu was definitely won this round. 

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Sometimes you have to be cruel to be kind

It’s 9.15pm, Thursday night, and I am on-call again in the acute medical unit. The day was long, unforgiving, and peppered with moments that had chipped away at my morale. The longing for Friday was growing stronger by the minute but sadly the list of jobs in front of me, contextualised in the chaos of the unit, was telling me to forget about Friday. Athough Thursday night, Friday felt utterly unattainable right now. I let out a sigh as I try and remove the negativity that was sweeping into my mind, and find some way to motivate myself….

“Excuse me”…

[“Oh bugger” I hear myself say inwardly] As I look up there are two people standing in front of me.

“Can you tell me where our mother is?”

This I CAN probably do – although I have no idea who she is. “Sure what’s her surname?”

They give it to me and I glance at the packed list of names on the AMU board. “She is in bay 2 bed 4. I am afraid I am not looking after your mother however so best to ask the nurse to direct you to the team looking after her. All the best” – I smile and look away starting to refocus on my list as they say “thank you” and wander off in the wrong direction..

“Other way” I smile and point down the hall.

Do I want to do a rectal examination first on the patient with abdominal pain or clerk in the drunk? Decisions decisions…

Before my slow brain can process this question I sense two people once again standing next to me. I look up and smile but inside I am just a little bit frustrated. “Is everything, alright?” I ask my two returning relatives.

“We were wondering if you could tell us about our mother? Maybe look up her blood results and tell us them?”

Oh dear, this is going to be awkward. I pause and look up before saying:

“I am really sorry – and while I can see how frustrating it is for you – I cannot do that.”

“But you could” the son quickly quips…

“Again I am sorry but I am not looking after your mother, know nothing about her case”

“We are just asking for the results though” the daughter and son chime together persistently.

“No. I am sorry but a result means nothing in isolation. It could be falsly reassuring or falsing worrying out of context.”

“We need your help”…pulling at my emotionally heart strings – which after the day I have had were a little loose and not particularly responsive.

I recapped again everything I had just said and in the end had to be very firm and blunt.

This, readers, is not an easy thing to do. If you read this and think I am being cruel, I can see you point. There are however responsibilities that I have. Professionally I knew that a blood result in isolation means nothing. A prime example is a raised white cell count. That means infection right? Well it could but it could also mean the patient is on therapeutic steroids, stress, or an allergic reaction for example. How do I know? I know, at this point they ask me – nothing about the patient. Say I do tell them and then it’s completely wrong? What if they finally talk to the team that are actually looking after their mother and they say “but the other doctor said…” – how does that make my relationship with my colleagues? I’ll tell you – strained.

On the other hand, I COMPLETELY get it. If I was looking for information about my mother in hospital, I would do exactly the same – hound every doctor I see until I get information. But, I am not – I am a doctor and as such I have to act responsibly as one. I never saw the two people again and of course I hope they found the information they were looking for and that their mother is alright. However, I have not regret over the way I dealt with that situation and if it comes up again – I would do the same.

Doctors will face these kind of emotional dilemmas a lot. It just goes with the job.

See you next week.

Dr Nick

My video debut on The Island with Bear Grylls!

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My video debut on The Island with Bear Grylls!

Ok, to explain, I was asked to make an online video for The Island with Bear Grylls on Channel 4 on some of the challenges to the body that the 13 men trying to survive on a desert island would experience. And here it is!
Note: I have to say I did completely cringe when I saw what the TV company had decided to put as my title but I promise you it was not my idea!

The 12 Day Tumble-Drier

Morning all,

The coffee is hot, my brain alert, my body slowly recovering, and the sun is rising. Not a bad Sunday morning by all accounts. It feels a particularly jubilant Sunday – not just because most of us, including myself, will have another gifted and treasured day off tomorrow before waltzing energetically into a slightly contracted 4 day week – but because my 12 day stint at work is over.

Now way back when on my surgerical rotation I had a 19 day stint – which, very nearly made me another statistic it was so bad. However, that involved surgical on-calls which, yes, are challenging, but in comparison to my first medical on-call weekend just gone, it was David and – this, Goliath.

If you’ve never had to work a weekend before let me shine a quick spot-light on the psychology of it. First of all, let me assure you – you are aware of this impending weekend ‘on-call’ shift weeks, if not months in advance, as it too in all likelihood will coincide with some cherished family event that you will no doubt (like many of the others) be unable to attend. The week before the weekend on-call is filled with dread as every exhausting day you do in that week is punctuated by the thought that there is NO weekend respite for you – just continuous exhaustion. The Friday is the most tragic as you awake, not with that “Friday feeling” but more a “Shit – I’m not even half way though the 12 days!” often accompanied by a groan that is only ever heard in times of extreme anguish. Ok, maybe that is over-kill a little. The weekend itself, we will talk about in a minute – as that is the main dish of this blog today. The week after the weekend on-call is a bit like a roller-coaster that is loaded with highs and lows. The low is definitely the monday afterwards as you awake (well in my case at least) in a flash, acutely unaware of what day it is and if you should or should not be going into work. And when you realise you do have to, it is as heart-breaking as seeing the horse in The Never Ending Story get stuck and sucked into the mud. As the week after on-call progresses you start to recover a little – you get a bit more sleep, don’t have to deal with so much on-call chaos, and the weekend of rest is slowly but surely emerging from the un-ending tunnel of exhaustion and you feel the desire to push towards it. The Friday is euphoria! You have survived! It a very strange twist you become super-charged and I found myself taking on more jobs that day, doing everything double-time, all in an effort to complete the 12 days with the ward in order and satisfaction soaking my mind.

And let me just say, the sleep after a 12 day stint, is just sublime. It makes me smile just thinking about it.

What makes me smile a little less is thinking about the weekend on-call. So in the effort to remain transparent, let’s talk about it.

During the weekend on-call, as a junior doctor, I am essentially the human sponge that gets to absorb all of the crap that happens during the acute admissions over the Saturday and Sunday. Let me explain how it works: when a person gets sick, they come to accident and emergency (A&E). The A&E staff then start treatment and triage the patient as either a surgical patient, a medical patient, or a patient who can be sent home straight from A&E. If it is a medical patient, they call the medical on-call team which consists of a junior doctor (me), a senior house officer, a medical registrar (God, basically), and the consultant. One of the team will then go and assess the patient and decide if they need to have a spell as an inpatient for treatment i.e. they are too unwell to go home. This patient is then transferred from an A&E bed, or chair, or cleaners cupboard (basically wherever there is space to put them) to the acute medical unit (AMU) where their treatment continues. As a junior doctor my jobs during on-call can include all manner of things from assessing and starting treatment, performing proceedures (bloods, urinary catheters etc), requesting investigations (urgent CT scans for spinal inujuries, for example) and being general dogs-body.

Oh, and you would realistically need a week to complete all the tasks you are asked to do….But you usually have about 20 minutes….followed by a look of disappointed on your seniors face when you inform them you have sadly not been able to bend time (just yet) and the allocated task is not finished. Now I know how the untrained pup feels when he does he pees over the floor and the owner tells me off.

So apart from not having anything to eat of drink from when I got up to have breakfast (0530) to when I got home at 10.30pm each night over the weekend (and probably only just avoiding developing acute kideny injury), let me share with you some of the highlights. As there are just SO many I have chosen the best (no, it’s not when “I finished the weekend”) and the worst.

The best was definitely putting in a chest drain and draining 1.2 litres of fluid out of this guy’s chest cavity while he sat on bed! To explain the guy who was in the UK from overseas while travelling had presented to A&E with increasing shortness of breath. An X-ray of his chest had shown that he had a massive left sided collection of fluid inside the cavity where his left lung sat. This is known as a pleural effusion and it meant that his lung had no space to expand when he took a breath in – as there was all this fluid in the way. As a result he was short of breath. Now the cause of the pleural effusion was a bit of a mystery – but given the specific demographics of this young man, his travel history, and the less than common presentation of a massive unilateral pleural effusion – exposure to some tropical infective process or tuberculosis, was at the top of the differential list. We worked up the patient with more blood tests and examination but knew that the best clues would lie in getting our hands on some of that pleural fluid. Plus, of course, in the process giving him some symptommatic relief for his shortness of breath! So, up comes my moment to do my first chest drain (well, a ‘thoracentisis’ more specifically as the drain wasnt left in place for long).

Let me explain what a thoracentis actually is. I sat the patient on the edge of the bed (like in the picture below) and then identified the ‘safe triangle’ of this guy’s chest. The safe triangle is a zone identified by various anatomical structures ( above the horizontal line of the nipple, lateral to the lateral wall of the pectoralis major, and medial to the anterior axillay line) – that is just so that you don’t hit something important like lung (causing it collapse [a pneumothorax]), or a puncture a major blood vessel. That would be very very bad. I then check this space with a portable ultrasound machine which helps me to identify the fluid and importantly any flappy bits of lung that sometimes get in the way. So once I had done all this, I inject some local anaesthetic, get my equipment ready, and then basically insert a rather large needle in between his ribs until fluid starts dripping out – that pleural effusion fluid that stopping his lung from expanding. Hey presto!

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Now, in the case of my thoracentisis, it all very nearly went quite badly wrong. You see this guy starts complaining of worsening shortness of breath. “Hmmm…this is not good” was my first thought as I glanced to my medical registrar who was watching me – hoping in the process to get a reassuring nod of “it’s ok” but instead got a look of “ut-oh, looks like you’ve won yourself a pneumothorax!”. Had I just punctured and collapsed this guy’s lung (i.e. a pneumothorax)? Time went rather slowly and I kept asking this guy if his breathing was getting better – every time he said no. So, being stubborn, I just kept asking the same question – until he said Yes – his breathing was feeling easier. See – persistance pays. And the reason for this symptom relief – well I had just drained 1.2 litres of fluid that had been squashing his left lung! And below is the actual photograph of my equipment and what I drained (see the full bowls and syringes…):

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It was epic! So much fun. Oh and the good news was after we had done another chest X-ray – no pneumothorax. Win. Win.

You know what I have rambled on so much about this experience, I am sure you all have better things to do with your day. So with that in mind we will leave my worst moment of on-call (a patient I had to literaly walk away from as I was about to loose my cool) and let’s just have a positive, cup is half full, day. The sun is out and I am sure we will all have a great week ahead.

Look out for one another. See you next week.

Dr Nick