The Junior Doctor Contract: Beware the Iron Fist in a Velvet Glove

I have just sat here for the last 45 minutes thinking about what to write about the junior doctor contract debate. My tea next to me has now run cold, the apple nicely oxidised and I’ve clearly neglected to pay attention to the programme on television as “Beth has a big decision to make….” though I’m not sure who Beth is nor the decision she’s making.

I am a calm man and it takes a lot to make me shift from that baseline. I would also like to think that I am a reasonably educated man, despite occasionally having the mentality to rival my current paediatric patients. The new junior doctor contract is circling us, the junior doctors, like a hungry vulture smelling fresh meat for the taking. All the while however, we, the men and women who have worked so tirelessly to earn the privilege to become doctors stand in formation, ready and willing to slip our hands out of our velvet gloves of calm and professionalism and show that yes, while gentle, we too possess an iron first.

I have my opinion of the contract. I also have my opinion on the precarious and risky nature of industrial action and its repercussions both within our ranks and on our relationship with the public and our patients (Mind you, I count myself lucky that most of my patients are under the age of 10 years – I doubt I’ll get much stick from them). With that said, the American novelist and social critic, James Baldwin sums up the position we, as doctors, are in when he once said, “not everything that is faced can be changed but nothing can be changed until it is faced”. Therefore, we have no choice but to face up and be counted.

While my emotions on this matter are quite simply a melting-pot, my support will be quietly unwavering – not through standing at a picket fence but my unceremoniously slipping off my velvet glove ready to show my iron fist. But until then, I will digress into a mere breath of immaturity and say thank you, Junior Doctor Contract, your timing is perfect – I just run out of toilet paper…

….it seems you will have your uses.

Loo roll

Dr Nick Knight

@Dr_NickKnight

Medicine for Little People

“Ah, the paediatrician is here” The midwife in the labour ward operating theatre states.

I go to look around for them, while having the sinking realisation that the ‘paediatrician’ – is me.

I smile, opting for the non-verbal response….as it feels less like lying.

So imagine that you have somebody in front of you who is sick. I mean really sick. Having laboured through medical school and clambered the slippery ladder of my first two years as a qualified doctor I should be able to handle this. It’s the simple principles of airway, breathing and circulation (your ABCs…).You see once you have stabilised these you can breathe a little, buy yourself some time, and work out the precise nature of what has made this person very sick.

Only problem is, the somebody in front of me who is sick is 3.5kg in weight, has a head circumference of 32 centimetres and is about as long as my forearm. Paediatric and neonatal (less than 4 weeks of age) medicine has just clubbed me around the face with a wet nappy and then pointed and laughed. I stand over the neonatal resuscitation table in the theatre having been handed a crying, slimy thing that has just produced from mum on the table – with a little help from the Obstetricians scalpel. I dry him off vigorously to stimulate a cry (a sound you always want to hear after a caesarean section as it means baby’s lungs are working) and look at this little fella. He is pink, crying, his chest is rising and falling (i.e. he’s breathing) and has a good heart rate when I listen with my stethoscope (all of which pretty much fills his chest).

Waiting for the baby to arrive on the neonatal table in theatres....

Waiting for the baby to arrive on the neonatal table in theatres….

For the first time in what feels like 5 minutes…I exhale.

Still this 3.5kg bundle that I am looking after over in the emergency theatre, rather unaccustomedly dressed in my pink theatre paediatric scrubs, needs antibiotics and close monitoring, as mum was a little unwell and there’s a chance of infection transference to him. That means I need to out a cannula in his vein.

DO YOU KNOW HOW SMALL A BABY’S VEIN IS!!!

My first attempt was a shambles. I technically, was over-powered by a baby. The second attempt was marred by my audience of the new dad watching me as I repeatedly poked his new-born child with a needle. The third attempt, by some miracle only known to higher powers, went it. I took some blood from the cannula to check for infection. Again, another new process I soon learned means squeezing the arm of a baby so blood vacuums out of the vein painfully slowly. This again looks horrible to the uninitiated eyes of the new dad…

The above is only a snapshot of the almost vertical learning curve that my new rotation in paediatrics and neonatal medicine has taught me. In the past 2 weeks (having been finally allowed back to work after the ‘hole in the lung’ incident…still ongoing), I have mastered the impossible rubik’s cube that is the baby grow, how to pick up a baby without terrifying its parents – or the baby, how to communicate with children from 2 years to 17 years (something that requires knowing what’s cool…not what you think is cool), and putting on my reassuring face when I really have no idea what is going on. Thankfully I am incredibly well supported by my senior team, who are great.

Paediatric and Neonatal medicine is not just a down-sized version of adult medicine – it is another world. No, make that another galaxy. Their physiology doesn’t behave the same as adults, the history taking and examination is a tailor-made, painstaking balancing act that would rival Indiana Jones when he swapped those bags of sand for the treasures, and the fear of missing a critical condition is something that focuses the mind to a degree that I haven’t experienced previously.

Lift to freedom at the end of my first long day on the Special Care Baby Unit.

Lift to freedom at the end of my first long day on the Special Care Baby Unit.

With all that said, I love it. Partly because it is such a privilege to look after lives that are not years, not months, not weeks or even days but HOURS old – and partly because I get to unleash my inner child as I try to engage with these children. An added bonus is I get to wear stickers with smiley faces on my I.D badge…

Right time to watch CBBC. You know, after-all, it’s important to know what the kids watch….

The Hospital At Night

It’s 0445am on Saturday 11th July and I am having a rare lull in my night shift. …

You know, the hospital at night is a unique, thought-provoking experience. It’s the time when all the hustle and bustle of the full complement of the daytime staff, relatives and heavy footfall across the WELCOME sign of the hospital disappears in the wake of silence and shadows. Instead you are left with a handful of nurses, doctors and cleaning staff echoeing their footsteps around the hospital corridors and wards. In a place which, during the day, you are side-stepping prams, patients, wheelchairs and stretchers, you can, at night you can stand uninvaded in the ground you hold.

That is one of the many reasons that I love night-shifts.

Now don’t get me wrong. This doesnt make me some daytime recluse, shying awaying from human contact – and daylight for that matter. I love it for it leaves my mind largely unitterupted to drift outside the box and ask – and try to answer – the questions that occupy my mind. Questions, that during the daytime, are drowned out by the emotional, physical and audible noise of hospital life.

For that reason, for me, at least there is a zen like state about night-shifts. You are one of a handful of doctors and healthcare members covering some 300 or more hosptial beds. You will – and do – get called to anything and everything. On a typical night I can expect to get called to a cardiac arrest (when someones heart stops), to possible new strokes, patients who fall out of bed, drug charts that need re-writing, family’s who need to be called to say their loved one is dying and they need to come in, and to write pain relief medication. All of these things indeed have happened since I started my shift at 9pm on Friday night.

As I go through a night shift, I find a very precious time. It’s a time to think about medicine, my career choices, – my life choices even. There is no magic to this – it is quite simply the silence of the night shift lets me do that. And to be honest, in a world that is as noisey as ours – with mobile phones and emails keeping us constantly connected – I welcome the opportunity for some peace and quiet. Of course, yes, the down side is that when it all goes wrong, and patients get really sick, and you are exhausted at 4am trying desperately to get a needle into their vein, the zen is gone, and the stress levels rise. You take the rough with the smooth.

I am sure I will be told I’m a little dramatic (well, my mum always says I have been one for theatrics even since I was a talking table in the school play) but I see the night shift as an adevnture! It is also a challenge for yourself. I like to see how well I can cope with the lack of sleep, with my body’s desperate desire to make me shut down into a low-power setting, and with the knowledge that I am part of only a small medical team and there is very little support outside of this. It teaches a certain degree of autonomy as a doctor and it pushes you to make decisions in the dead of night that during the daytime you could very easily defer to someone else. That ‘push’ makes us better doctors – and I would hope that means better patient care.

[15 minute pause in writing this]

As I have just learned too – the night shift is a rare opportunity to practice the things you don’t often get to do in the daytime; Like, as I have just done, to put a cannula into the vein of a screaming 4 year old boy. Now putting a cannula (they’re the tube that go into the veins to give medicine and fluids) in a adult can be tricky enough but when you are faced with an arms flairing, lungs open and vocal cords roaring, 4 year old grissler – it is an alltogether more challenging task. Still, after using two nurses and one mother to help me (and I must confess, on the second attempt), we managed to get the cannula in. In a vocal range that could rival Maria Carey, all it took to appease this little one was a sticker with a smiling panda on it. To be 4 again.

The sun is rising and the London is waking up once more. You may not all have a night shift to find your zen peace and quite but do try and find some part of your day or week that allows you the time to properly digest your thoughts rather than let them fester and give your brain indigestion.

Right, time for a coffee and a stroll of the wards….

Nick

The Human Spirit.

It’s Monday. I should be sleeping since my week of night shifts starts this evening. Thanks, however, to the 18 inch electrician’s drill bit that is currently working its way through the downstairs flat exterior walls, and the road works outside – sleep is not an option.  The entire building is vibrating! But you know, I look at it with a peaceful mind.

Why?

Quite simply because when you hear of the tragic horrors of events in Tunisia last week (and similar unspeakable atrocities that go on around the world – heard and unheard of), you cannot but realise how precious life is. How precious our families are. How precious our friends are.

Yes we live in an era of instability, concern and unrest but we also live in a world where people are willing to look after others, to put themselves in harm’s way in order to protect to their very last breath those they love – and for complete strangers. We too live in a world where men and women display courage and resolve by trying to stop pain, suffering and distress – people who have no responsibility to even try – such as the builders who were throwing rubble down on the individual who committed those murders as he escaped through the streets.

The human spirit is indelible, strong and etched in all of us. We may walk around in a society where individuals fear to speak to strangers, where heads are held down and eye contact eschewed.  But when individuals are in real need, I still believe in us, I still believe in the human spirit, and that intangible innate call to protect and help.

I would never dream draw parallels to those events in Tunisia but what I can say is that at the end of every day in hospital, I leave with an albeit tired smile on my face, forcing myself to discharge the negativity that can understandable creep into my mind, and instead recall those small, unrecognised, moments where the human spirit shows itself.

Never give up on the human spirit. Please. We need it now more than ever.

Nick

Making The Decisions That You Didn’t Think You Could

There aren’t many sounds that can haunt me. In fact there is only one really. That, ladies and gentleman is the sound of the pager that I have to carry when on-call. Just to bring you up to speed, an ‘on-call’ is typically outside of the normal working hours when all the regular doctors that manage their respective ward patients have gone home – so after 7pm until 8am or, at the entire weekend. It is then the responsibility of the on-call team to respond to any medical issues in the hospital.

A medical on-call team consists a Foundation Year One Doctor (F1), a Senior House Officer (SHO), that’s me), and a registrar (with of course a consultant available if needed).  Between the three of us, we manage the entire cohort of medical inpatients – which in my hospital is a rather heart-sapping 300 plus patients.

So the weekend just gone, I was the medical on-call SHO. Saturday morning I clipped on the pager into my scrub trousers at 8am, took the final resignatory sip of my coffee, demolished a banana in one, and enjoyed the feel of comfy chair for a minute, knowing full well that I may not get to experience any of these simple pleasures for the next 12 hours.

And then it began.

“BLEEP BLEEP”

The first call was a patient acutely unwell, with oxygen levels dropping below a safe level to oxygenate organs like the heart and brain. I told them I’d be right there. However, as Sepp Blatter knows all too well, life doesn’t always work out the way we want. “BLEEP BLEEP” – a second bleep echoes from my scrub pocket as I’m walking towards the rapidly oxygen-starved patient. The voice at the end of the mobile when I call the page number tells me they have a patient who has just spiked a temperature, has a heart rate of 140 (and they’re only lying in bed not running a marathon, remember) and a blood pressure low enough to be in their boots. Still walking towards the first patient I was bleeped about, I tell the anonymous nurses voice I’ll be there as soon as I can, to push some fluids through the patient’s drip, and put up some paracetamol through a drip. They tell me they need me there right now.  Sorry, I have a higher priority patient. Brutal but true.

“BLEEP BLEEP”, “BLEEP BLEEP”…two more bleeps come through as I arrive at the first patient. The nurses on the end of the phone I speak to (as I am mouthing and pointing to the other nurse at our first oxygen starved patient to put the high flow non-rebreathe oxygen mask on and crank up the oxygen in a fashion that explains why I was never any good at charades) deliver me two more blows – a patient has fallen out of bed and has a deep laceration to the forehead and is more drowsy, and another patient on the coronary care unit has central crushing chest pain.

Those four patients were a snapshot of my first 25 minutes on-call last Saturday. My coffee was probably still warm, and my comfy chair still with my bum impression on it. How things can change so quickly!

Plus, I had 11 hours and 35 minutes left of the shift.

Now many of you may be expecting me to be writing this from some padded cell, drowsy from sedative, with one arm of out the straight jacket, having completely lost my mind at such a weekend. However, I am pleased to say I am not. In fact, I am sat in my living room enjoying the buzz of Londoners as they comes to life for another busy day in the Big Smoke. I have, you see, experienced many weekends like this now. The first few, I must confess, I did not cope, became stressed beyond my own expectations, and returned home feeling like I had not only let down my patients but let down the perception of who I thought I was as well. I am not sure which one was worse. It left me with many sleepless nights.

But experience is a tricky beast. You see you have to give yourself enough experience to really grow and adapt. The second and third on-call weekends were still too early in on in my experience journey to truly get to grips with how I was adapting, learning and growing.

Then I started to get better. I started to see my clearly what patients were critical requiring IMMEDIATE response, what patients were URGENT but not critical, what were patients were IMPORTANT but not time-sensitive, and what patients reviews were NOT ESSENTIAL (if time were to run out). Now I can fully appreciate that to many this can seem callous. The truth is that you quite simply have to see patients in the order that they are most likely to die.

So, my patient with low oxygen was at greatest risk, then the low blood pressure patient, then the chest pain (possible heart attack), and then the head injury. What I haven’t mentioned is that as an on-call doctor you begin to work out what you can do remotely over the phone. So, while I am seeing the low oxygen patient, I can ask the nursing staff if they can give the low blood pressure patient some fluids through a drip, put them on a heart monitor, have 5 minute cycled blood pressure measurements, and ask them to page me again if it falls below a certain number (e.g. Systolic Blood pressure of 80). For the chest pain I can ask for an ECG (a heart tracing), heart rate and blood pressure, and give them some medicine to relieve the pain. For the head injury I can ask the nurses to get the patient into bed, put a pressure dressing on the laceration and do half hourly neuro-observations to make sure he isn’t having signs of a bleed within the brain. The reality is, I may not get to some of these patients for well over 90 minutes.

So I suppose the bottom line is that life as a weekend on-call as a doctor has taught me some lessons that we can apply to all walks of our lives:

  1. We can’t bend time
  2. We can only be in one place at a time
  3. Stressing about what is beyond our control is a waste of time
  4. The more stressful and heavier the workload becomes, the calmer you need to become
  5. Indecision is worse than the wrong decision
  6. A sense of humour goes a long way

I am definitely still a work in progress (I know this as I still have the most vivid, real dreams of patients I have seen the nights after an on-call) but I sit back this morning with a smile on face, feet up on the sofa and a coffee in my hand, knowing that I am stepping in the right direction.

Have a great week.

Nick

Doubt

It happens every 4 months, so by now I really shouldn’t get surprised by it – I am transferred on my conveyer belt of doctor training to a new specialty in medicine. The frustrating thing about this move is not that I am resistant to change or experiencing new and fascinating (ok, maybe not always) aspects of medicine but rather that 4 months is just the right about of time to be settled into a job. At 3 months, 3 weeks and 6 days I know the regular staff, the working day routine, what to do and what not to do (and the definitely what not to dos), and I am essentially settled. Life is good.

Then, all of suddent as that 3rd week of the 3rd month rounds itself off to the odd 7th day, suddenly the trap door opens below me and I am dropped into a whole world of doubt. 

You see what happens is, you finish one 4 month rotation on one day and the next (typically a Wednesday so that you can only do so much damage in the three days before the weekend) you start a brand new one. The treadmill on the new rotation doesn’t start on a slow speed with a gradual incline – it starts at 100% incline and break neck, eye-watering speed. Last Wednesday I was all of a sudden presented with thirty complex medical patients whom I knew nothing about, a ward that I had all the orientated ability of school kid on day 1 of their duke of Edinburgh scheme -and to cap things off I had my lucky pen had run out of ink. Never underestimate the importance of a good pen.

As first days go it was, well, awful. How do I measure it? Well, there are lots of parameters from the number of patient left alive at the end of a day, the number of relatives who have shouted at you, the number of toilet breaks (the number of toilet breaks inversely proportional to the busyness of the day), or the ability to consume food – more than the last Haribo sweet on the nurses station that has by that point been grazed by a two dozen partially washed hands and splashed with a hint of alcohol hang gel-MRSA fusion. That first day was however measured by the ultimate yardstick – the time you left work. In the case of day one of my new rotation this was a punchy 2 hours and 15 minutes after my shift formally finished. 

Joking aside, I am really not a fan of this swap period. It’s not because the new medical team are not nice or receptive – far from it – or that I have some longing to remain in my old rotation (as much as A&E was amazing, I’m glad to get my weekends back) since I am naturally hard wired to want to stretch myself – whether I enjoy it or not. The reason, rather ashamedly is that I always end up getting floods of doubt about my skill as a doctor.

The start of a rotation is always very exposing you see – it is raw, fast paced, unforgiving with time not waiting for you to catch up or get up to speed. With this fate I inevitably end up judging myself harshly, filling with doubt and worrying about my skill as a doctor. As such it was fair to say I hated my first day on the medical ward last week – an assault on self-perceived professional competence. Now as someone who sleeps like a log (and I mean really does not move until they awake with that tiny pillow-pool of dribble cradling the nights saliva) it rare for me to sleep badly. 

The first two nights after I started this rotation I slept awfully. Definitely no saliva pools but instead replaced with sore eyes that had stared at the ceiling of my childhood bedroom (home for Easter for the free chocolate obviously) from 3am until sunrise as I ruminate and dwell on the 4 months ahead. On the third night however when I awoke again at 3am I had a change of heart:

Sod this.

Having been enthralled with a bit of Bear Grylls Mission Survive on TVS the night before, I asked myself how can I survive better and change my mindset? This sounds ridiculous to many I’m sure but recognition of a problem, whatever it is, is the first step, however you find it. Plus, we all seek inspiration from different sources – and for me, not in an idylistic way, but more a respect of what he represents, find this in Bear Grylls. With that said, not to sound like narcissistic (something I’ve been accused of in the past) but I believe my parents have raised me and my brother incredibly well and given us all the tools we need to face challenges. So with this in mind at 4am I wrote a list. Now, I may regret this as I know some of my colleagues are aware of my blog now and may read this – but if I want to be truthful to the blog – I need not let that worry me. So here is the exact list I wrote:

  

We all encounter challenges in life; From the complex to the mudane. How we approach them is effected by an abundance of factors some of which are simply beyond our control. Someone once said, “if you can’t change something, then change the way you feel about it”. Composure, calm, positivity, tenacity, focus, good humour, all supplemented with support and teamwork, are all essential to win over any doubt that may creep into your mind. Looking after the body and mind with good hydration and nutrition is as critical too – unless of course you want to run your batteries dry.

I can succeed in this rotation just as you can succeed with whatever challenge you have this week. So with that, knock away the negativity and doubt, drive in the positivity and I’ll see you on the other side….

Nick

Back to (Relative) Normality

After 4 months, 75 shifts averaging 10 hours each, no social life and a strange new appreciation for daytime television and solitude, I have finally come to the end of my rotation in the Accident and Emergency (A&E) Department. The cloak of darkness is lifted and once again I will be returning to join Londoners on their daily morning commute; this a far cry from the 3pm, 4pm, or 10pm nocturnal shuffle that I would make towards work to start yet another evening or night shift. Weekends, ah weekends, how I look forward to you as well – no longer dominated by the quandary of how to get to work with the inevitable weekend rail engineering works but by which side shall I lay on as I doze, enjoying a lazy Saturday morning in bed.

I recall looking at my rota, some 4 months ago, and being filled with both horror and confusion. Afterall – surely I am not expected to work 6pm until 2pm Monday to Friday and then 3pm until 3am on Saturday and Sunday with only one day off before starting again?! Oh, no wait, I am. Now, however, I look at the rota with a real sense of pride, puffing my chest from a much diminished frame (I realised I have lost over a stone and a half since working in A&E), for not only have I had a the most fantastic time working in A&E with a wonderful team of people who encapsulate the Commando motto of “cheerfulness in adversity” (thanks Bear Grylls, for that nugget) but I have survived probably the hardest rota that I will encounter on my road to becoming a GP. Now if you didn’t know, I have spoken about life in A&E recently this week in the Independent (http://www.independent.co.uk/life-style/health-and-families/features/life-inside-ae-the-highs-the-lows-and-the-grief-is-something-that-echoes-across-all-hospitals-around-the-world-10132683.html) What I perhaps did not mention though was how humbling a place A&E is. Once you look past the chaos, the shouting, and the stress that, on some shifts more than others, seems to hang in the air, there are acts of kindness and compassion in all direction. Too many to list and perhaps, moments like that should be left in their moment and not revisited.

Last night, there was however, one patient that made me think about the appropriateness of some medical decisions we make. A 90 year old nursing home resident with advanced dementia, bed-bound, requiring all her care needs supported by somebody else, with bed sores, and a DO NOT RESUSCITATE order in place (at the wishes of this patient herself) is rushed into the resuscitation room via a blue light ambulance for a reduced level of consciousness. She had no temperature, was not infected. She had not appeared to have had a huge stroke. Looking at her, with all the information available it was clear that this was an old lady who was quite simply dying. She was in her comfortable nursing home with her own room, nurses that knew her, photos of her family and memories that she had sadly slowed had taken from her as dementia gripped. Why the hell bring her into a packed hospital ward to die. After talking with the family it was clear we all shared the same view – get her back to the nursing home to have a good death. Yes, a ‘good death’ is part of good medical practice as important as the life before it. A good death has comfort, dignity and is free of pain and distress. My point is, we should not treat everything and everyone just because we can. We have a mind, emotions and sense – let’s use it.

In an NHS era where I was supposed to make sure that I have seen and treated my patient within 4 hours (and by the way, referred to a medical or surgical team within 2 hours – tricky if you don’t get to the see the patient because there is nowhere to see them in a full A&E and when you do – they are already on 3 hours and 20 minutes), we, as doctors and health care professionals, are always expected – dare I say it pressured sometimes – to treat patients as a statistic. A statistic that we are desperately trying to keep below that horrible bloody number – 4. If I hear someone mention 4 hours this, 4 hours that, anymore, I may have to defect to Australia – and I don’t do well in the sun. Personally, I am refusing to treat any patient as a statistic – and if that patient breaches the 4 hour mark then so be it. My justification – a guarantee from me that they have received the appropriate care and investigations in a sensibly, safe and timely manner.

Perhaps people need to be reminded of the old Aesop’s fable – the tortoise and the hare.

Have a great weekend everyone,

Nick