No Minute The Same

It’s been said that junior doctors are paper-pushers, secretaries to the real doctors (no slur on medical secretaries as that is hard work in its own right – my mum is one!), a bit clueless, and the cannon-fodder for the ward while the real doctors get on with the work of curing, treating and healing. This always makes me smile! Partly because it has some semblence of truth at times and partly because at times, well, it couldnt be further from the truth! Often though it sits somewhere in the middle. Maybe as my own means of coping, I see us, as junior doctors, as the apprentices – we are there to do the grunt work yes, grab the experience in treating patients for ourselves, and learning from the seasonsed experienced doctors and nurses that we work with. What this means, ladies and gents, is that no day – is ever the same. In fact, when I think about one particular day last week….no minute was ever the same!

Thursday 12th 2014…

Having survived actually waking up, negotiating the obstacles littered on my bedroom floor (very unlike me, and an indicator of my week thus far), managing to work the shower with only half of one eye open, and then making it into work, having not fallen asleep on the train, I step onto the ward at 7.15am. As I collapse into a chair on the ward, drowning out the sounds of alarms and chatter, I realise with some desperation that I am, once again, on my own on the ward – no other doctor but me. I tell you, how, on that day would I have wished I had someone else to share the work-load with. I contemplated bribing another doctor to come and join me…but felt the General Medical Council (GMC) who regulate doctors may not approve of this.

Right, with the scene set and the characters in play, let the day begin.

The first task is over very quickly – the lady I had planned to discharge back to her nursing home has not had her loading dose of warfarin, a blood thinning tablet, given and so I decide that it’s not safe to discharge her not properly anticoagulated (the risk of another stroke is too high). I have to let the Ward Sister know (she’s the real boss) – and the patient. Not good. Then a gentleman in one of the side rooms starts to deteriorate clinically – he is tachycardic, hypotensive with a tachypnoea and increasing oxygen requirement. All that means he is that he is very unwell with his heart and breathing systems under increasing stress. I assess him – airway, breathing, circulation, and so on, make a plan and then inform the family. In the case of this patient he is sadly for palliation only. This means our focus is on comfort, and supportive measures. The family are accepting of the situation and I encourage them to come in as he is likely to have less than 24 hours left. It is never easy speaking to families on these matters not matter the level of experience. If it is easy – you have become desensitised…and that is dangerous.

“BLEEP BLEEP!!”

I draw some breath – that’s the on-call bleep going off – but – it is only 10am?! I still have to do my entire day job of looking after my regular patients on my ward before I can safely ad reliably do on-call duties – after all there are NO other doctors to look after them. I answer the bleep and it’s the on-call medical registrar asking when I think i’ll be free. By 3pm I said, closing my eyes and shaking my head as I said it….there’s no way I’d be free by then! Why did I say 3pm. Nick – you idiot.

Now the clock is truly ticking…I have some real work to do!

As I put down the phone, I am informed by the nursing staff that the Nepalese translator for a scheduled family meeting is here. I still have only seen 3 patients on the ward round. This is not good. In fact, let’s be honest – it’s very bad. But still, I knew my Plan A for this day was never going to come true to form – so I made the decision to just role with the punches today and attempt to come out unscathed. Once you make that decision and stop forcing control on a situation it is amazing how much more peaceful you become – or at least I do. The Nepalese family meeting lasts 45 minutes in a tiny, swelting room to the side of the ward. It’s fascinating to learn about a new culture – and having been to Nepal back during my PhD, I am particularly fond of the Nepalese culture and people. Incredibly warm and giving. The benefit of the meeting too is that I get to have a cup of tea and some food during the meeting. Win Win.

Walking back onto the ward, with my mind wandering to the beauty of  Everest Base Camp all those years ago, reality snatches me back. “Mrs Smith [not her real name] has no intravenous access and she is for surgery tomorrow so needs it”. This, ladies and gentlemen, is a true heart sink moment – Mrs Smith is IMPOSSIBLE to get a cannula (a small tube in a vein to take bloods and give medicines directly into the blood stream) into. I have tried before and know this is a non-starter. So where do you go in a situation like this….that’s easy – my old friends from my last rotation in intensive care. I stroll down and grab the ITU registrar who is luckily free. It’s a nice breather to be off the ward and have a catch up on the gossip from ITU – I miss it so much. Sadly, after twenty minutes of trying the ITU reg and I make eye contact above the patient’s own eyeline – it says all that needs to be said – this truly IS impossible. I have never had a vein-less patient like this before! And with that, the surgery is delayed until next week until I can get intravenous access requiring radiological guidance. And that doesnt happen at the drop of a hat….

Only 7 patients seen, 11 to go. It’s already 11.45am.

Walking to my next patient I am met by a very distressed relative. And I mean very distressed. The ward corridor is no place to help a patient or their family so I guide her into an empty side room. This takes a further 25 minutes to calm her down, go through their relatives case and put their mind at ease. I am so so mentally tired at this point. I just want to curl up in a ball.

I think about lunch momentarily will staring at my list of jobs I need to do with a tunnel-visioned gaze..until the bleep shatters the silence. It’s a cardiac arrest. Now as part of the on-call team that day I am supposed to attend these. This one, in the opposite end of the hospital, means I leave the ward and run (well, walk as quickly as I can like those odd Power Walkers) to the ward. When I arrive chest compressions are ongoing, the anaestist is dealing with the patient’s airway and there is a flurry of activity. It was a clear case of too many cooks and after checking with the medical registrar running the arrest call that he didnt need me, I returned to the ward (via the caffeteria for a coffee and lunch!) to continue seeinng my patients.

The next couple of hours as an uncontrolled whirl of seeing patients, re-writing drug charts, dealing with odd jobs, being shouted at my the clinical imaging department (it was their fault not mine by the way), and answering the telephone. I discharge a young lady who, to be honest, didnt belong on a stroke ward anyway (she was far too young and it was clearly not a stroke!), and was happy to see her go. This however was not an easy process – I have to coordinate her medications with pharmacy and the discharge team. As an aside, the biggest show-stopper of my day is an impromptu discharge like this. You see, there you are, running around, trying to see the patients, and you are suddenly tasked with sitting down and writing a detailed discharge summary (containing clinical history, past medical history, invesitagtions performed, plan for follow up and so on) and prescribe the drugs to take away – this can take time to do. It’s like being shown a red traffic light every 100m when you are in a hurry to get somewhere!

It’s 4pm. The on-call bleep goes off. I sit down at the ward desk, having been beckoned to accident and emergency to start seeing new medical patients on ‘The Take’ (that’s doctor speak for the new patients that are admitted during your on-call shift i.e. you take them in), and contemplate the state of the ward. On the balance of things, it is under control. Not perfect, but under control. I chat to the nurses and therapy team on the ward so they know what is going on and where I will be. It’s also a chance to check that there are no burning issues bothering them that I can help with. And with a few odd jobs completed, I plan to off to A&E to start my on-call. It’s 4.20pm. I have 5 hours of on-call to do. My stomach grumbles – I wish I had had some more weetabix that morning! Just as I do though one of the staff nurses brings me a can of coke. She said to me that she could see it’s been a tough day – and that maybe I could do with this. It was such a nice gesture and I was so so grateful for it – not just for the drink and quick hit of sugar but for the reminder that I have a great team on the ward – they all work so so hard and I hope I help them as much as they help me. TEAM: Together Everyone Achieves More.

Ok, I am sure you are getting bored of reading this lengthy blog entry so I will be quick. The on-call serves up 5 hours of unrelenting chaos – but fun chaos all the same! I see urosepsis (that’s a urine infection that has spread to the blood and made the patient very unwell) in a Nepalese patient who didnt speak any English; An acute heart attack in a 50 year old Italian man with the set of risk factors were classical (smoker, over weight, poor exercise, high stress, poor diet, high blood pressure, strong family history of heart attacks); A young lady with gastroparesis (your gut stops moving food along and you get symptoms of vomiting etc); and a old chap with an untreated chest infection. I even manage to grab 5 minutes outside in the mid-evening sunshine with the on-call senior house officer – a friend of mine – to catch up on the gossip and chat about anything but medicine for a few minutes.

Finally after the 12 hours plus of running about, thinking far beyong my poor brains capacity, and thinking about food, at 9.30pm we hand over any jobs to the night team who will look after the hospital until 8am, grab a train at 10pm,  and crash into bed at 11pm.

As my eyes slowly close in the dark and solace of my bedroom, the whites of my eyes suddenly pierce the black as I realise….

“Bugger – It’s Friday 13th tomorrow….”

I’m too tired to care. Time to dream.

Bed 4

Bed 4 is young enough that she really shouldn’t be on the stroke ward. She has multiple organ issues – her heart has dilated chambers that mean it cannot function effectively as a pump to send blood to the rest of the body. Her legs have swollen with pitting oedema, as a result of her cardaic failure,  making her skin tight and at increased risk of infections like cellulitis. Her lungs are battling an infection because on the way to hospital she vomited and as a result of an ineffective swallow (due to her stroke), ‘aspirated’ (swallowed down into her lungs) her vomit. That means Bed 4 now has a right lower zone aspiration pneumonia. She will require intravenous antibiotics through a cannula in her vein. This is looking red and painful from superficial thrombophlebitis. On top of the problems with her lungs and her heart, Bed 4 has also had a massive, debilitating stroke. This has left Bed 4 with a functional right sided weakness and an inability to speak – known as aphasia. Because of the location of the stroke she can no longer swallow either and has to be fed by a nasogastric (nose to stomach) fine bore tube. Bed 4 has multiple organ pathologies and is being treated aggressively with medicines through drips and medicines to tackle them. Even at a young age, if this person’s heart stops, the medical team would not resuscitate her. She would be highly unlikely to survive a resuscitation attempt with her heart in such poor condition.
Of course Bed 4 is not Bed 4.
Bed 4 is a mother, a daughter, and a wife. She is a best friend to somebody, a confidant to a dear friend, a fan of some terrible TV programme probably (who isnt!). She has a name, a personality and feelings. She is no doubt scared, unsure of the future and confused by all the frenzied activity around her.
Bed 4 is a composite of multiple patients I have seen, and of course, fictional. However, this type of hospital patient is VERY real, trust me.
We live in a very faced paced world. We meet people off-line, on-line and rarely get a chance to stop and really know the strangers that we encounter in life. Afterall, we are too busy, going somewhere, preoccupied with our own problems and don’t have time to understand someone else. Besides, we need to check Facebook, see if we have a message from that person we liked on an online dating website or rush off another busy appointment. We are often passing ships in the day – and the night at times. Life has become fleeting if you let it.
And then it struck me – amongst all the rush of life, my stroke ward can be the parallel to this. My patients are here for some time, undergoing intensive neurorehabilitation with physiotherapists, occupational therapists, speech and language therapists, and dietitians. Then there are us, the doctors, and the nurses who aim to meet their medical needs like treating chest and urine infections that regularly crop up from prolonged hospital stays and urinary catheterisation. Now because they are here for some time…I am lucky enough to get to know them.
Every morning when I come onto the ward, I fill up my water bottle and I put my arm around the ward sister (that’s the boss) asking her “Today is going to be a good day, right?”, before walking into the three bays of patients a saying good morning each. I don’t do it because I think it looks good for the hospital, or I am trying to be a cheeseball (ignore the terrible use of American slang – I heard it on the London underground and it’s stuck in my head) – I do it because I want a warm, open, flowing team environment – And the patient is the biggest part of that team. TEAM: Together Everyone Achieves More.
As the days go by and I learn what makes my patients tick, their subtle ways, the ones that get nervous, the ones that like a joke and a laugh. You  begin to be able to tailor your ward-round to not only meet those medical needs (which of course, come first as a matter of duty), but to meet their psychological needs. What’s more, Bed 4, is no longer Bed 4 – she is the patient who lights up with a smile when her daughter comes to visit and attempts the yo-yo trick in front of her that she can never do. She should never be bed 4 infact.
And this IS important. It is important because patients are beginning to feel like a bed number, a disease or illness, rather than a person. This is very very wrong. Imagine if you were in hospital, or your mum, brother or grandfather was – do you want them to be referred to as a Bed Number? Of course not. It requires a cultural change within hospitals. And of course, this is is also something that is not going unnoticed either – just see what this young lady had to experience:
Dr granger
This is disappointing in itself, isnt it. After-all, what has changed over the years to stop us looking and seeing the person before the disease or bed space in the first place?
Something lighter next week, I promise…
Dr Nick

Attitude: Lessons From an Astronaut

This week I was left in a little bit of a quandary. There is so much to talk about that, well, I wasnt really too sure where to begin or what to pick. We could spend the next ten minutes talking about the brilliant British Association of Sports and Exercise Medicine (BASEM) conference that I attended this Saturday on “Exercise in Health and Disease”. This served up an array of in depth presentations on the levels of physical INactivity, not just in the UK but globally, and, among other key messages, how ‘prescribing exercise’ can help remedy this. The most striking takeway, I must add, before moving on, was learning that low fitness levels have been demonstrated to kill more Americans than smoking, diabetes and obesity combined. For those of you shouting at the screen, demanding this unbelievable statement, type “Aerobics Center Longitudinal Study” in your Internet Search Engine. Now, I could also have spent the next ten minutes talking about my horrendous attempts to Salsa dance on Saturday night. I could say that this was my inspired attempt of increased physical activity after a day of learning about the risks associated with inactivity – but sadly I was pressured into going by my housemates. After a one hour lesson in the middle of a packed salsa bar I was still rubbish, had left one girl actively avoiding me after I nearly snapped her ankle with the giant Timberland boots I was wearing (I had, afterall just come directly from a conference, more than just a little unprepared!), and once the true salsa kings and queens hit the dancefloor, knew that it was time to escape and put the kettle on. I was however asked to dance by one girl. Thinking, well, maybe my moves werent that bad after-all, it turns out I was just the least letchy man in the bar and she felt I was a safe option. Small victories.

But instead of all that, I want to focus on ‘attitude’. If you look up attitude in the English Oxford Dictionary it defines it as “a settle way of thinking or feeling about something”. Our attitudes permeate every facet of our lives from the insignificant daily decisions over what TV show to watch to the significant life changing decisions that we all will encounter with time. It affects how we work, play and interact with others. Our attitudes can often highlight the best in us – and the worst. With time attitudes can change as we gain more insight, information and experience.

Now I am going to be honest – I havent been too happy with my attitude recently. I am, it has to be said, a constant dreamer – I aspire to things that seem, at least at the moment, impossible. That impossibility doesnt put me off, and I would like to think that as I have gotten older I stay more grounded while striving for the seemingly impossible. However, this positive attitude I have also comes hand in hand with my worst trait – impatience. I am an impatient person and I know that everyone who knows me well enough will nod in syncronised agreement. Even I am nodding! That impatience starts to erode little by little into my positive attitude to my goals in life. Things don’t happen as quickly as I would like them to, barriers that are in the way frustrate me, and I have increasingly felt that my head was dropping. That is a difficult thing for me to say, as, despite my seemingly grumpy nature sometimes I am a very positive person – I believe we can all achieve our goals, be happy and inspire each other along the way.

There is a little part of me that hopes you all sort of know what I am experiencing. For attitude is key to how to live our lives – as I was saying earlier – whether that be at work, in play, or in family life. For me, the most concrete example I can give you is work. Without a regular senior house officer, without a regular registrar on the ward, I have felt like a one man team looking after 18 patients. It felt that every job from the smallest to the largest with varying degrees of clinical implication, was resting on me. I know that is a feeling that all junior doctors will likely experience from time to time. And of course in reality there is always support – and I know I can always walk to another ward and ask for help when it is needed – and indeed do. The reality is that I was starting to dread going into work – my attitude was becoming increasingly negative. I would dread the endless barrage of problems, requests, tasks that would start from the minute I walked on the ward. And you know, the funniest sensation of all (for someone who is pretty quiet and likes his time alone), is that it felt lonely – I really felt like a one man team. No man is an island, afterall. Bottom line is that I had developed a negative attitude towards work – and that was poisonous.

That however is changing, I am pleased to say.

Why? Well, I had a few doses of reality checks from a few people and I picked up a book that, currently, I am finding very hard to put down. Nope, it’s not a self help guide by Katie Price or Kerri Katona but a book by a Canadian Astronaut. His name is Chris Hadfield and he has written a book about his career called “An Astraonaut’s Guide To Life: On Earth”. It is just superb. I spent 4 hours with my feet up on Sunday afternoon on the balcony reading it just absorbing each word from each chapter I digested.

astro

Did you know that an astronaut can train their entire lives – put in 1000s of hours of classroom theory, spend months and months away from their family, take endless exams that never stop, constantly learn new skills from a new language (for example if they are going to go to space and live with Russian cosmonauts) to fixing a toilet in zero gravity – and all with the knowledge that they may NEVER actually get to go into space. Why is this relevant to this blog about attitude? Because it takes an unbelievably strong, positive, driven, and grounded attitude to commit to that with the knowledge that you might never make it beyond the Earth’s stratosphere. This man, Chis Hadfield, or Commander Chris Hadfield, I should say, has an attitude that inspires me. He does things in a manner that I would like to think one day I could. Not go to space obviously (!) but apply it to medicine, my life and the people close to me. Let me give you a few examples: firstly there is the time that he knew we was going to apply to a canadian space agency. He spent months preparing his CV and the 500 page documentation of evidence alongside it. Then he thought, what if they were french-canadian? So he translated it all into French – and then ensured he could answer and discuss it all in French. Then there is the time that he was involved with ground control for a new Russian spaceshuttle. Now he new he would never be going up in space in that shuttle but all the same asked to be trained in it (giving up his own personal time) – all so that he could better understand and therefore help the Russians when up in the shuttle. Finally there was the time after his second space flight, 5 years after his first one, that he was told it was unlikely he would ever go up into space again….his attitude was, “well, you never know, so I should be ready” – he continued to train and ELEVEN years later he went up to space again as Commander – all because he always stayed ready and had a positive attitude. What’s more inspiring and brings hope is that, in case you are thinking he was some work-addicted junkie, he had a lovely wife and three children who shared in it all.

So when I now think about my attitude to work, I try and think a little more like that. To be honest, I think I have that innately within me but in the last few weeks it has dipped and I let my head drop. My head is now up, I am looking forward to the challenge that work brings, what I can learn and how I can, more patiently, progress. What I also now what to do is make sure that I do the same for the others around me – my little team down in my basement hospital ward – the nurses, the health care assistants, the physiotherapists etc, the patients – and their families. It might seem silly but it is a brilliant place to work on having the right attitude. It is a place that is stressful, a little chaotic and with daily challenges. I am now, more than ever, determined to be a positive doctor within the NHS, with good skills, and more importantly perhaps, a good attitude – not one who hangs their head, moans about the ‘system’, and sulks at the endless exams. And if ever I feel like I am heading that way again, I will just dip back into Commander Chris Hadfields’s book and re-align my attitude.

And yes, of course, I will be writing to NASA to ask if I can visit and learn a little about space medicine!

Have a positive week, all.

Nick