Recovery: Don’t let it be in your blind spot

This week I wanted to talk about recovery. Now recovery is a word that is used in all sorts of contexts isn’t it – from recovery after exercise to a tough day at work to a horrible psychological event or even a break up. I even recover from a tense episode of X-factor from time to time…

The fact remains however that recovery is incredibly to us. It is about preparing the body and mind for the next iteration, the next stage of being or action. And it is bloody important for without it we can significantly disadvantage ourself.

Of course it’s not just important because we all enjoy some time off from that event, job, task (or person!) – but because in order to perform well – whether that be physically or mentally – we need to have that period of time to heal, reflect, digest and learn from the event. 

And I bet you know what I mean it I say that we fail to do that – when we fail to allow recovery to take place – we may find we begin to struggle to perform as well as during the previous event. As an added factor, stress levels can too build as performance drops, so compounding the effects of what was already inadequate recovery.

For me, I’m going the end of two weeks off from a long stretch of busy paediatric accident and emergency shifts followed by a set of night shifts in paediatrics. I was both physically and mentally exhausted. Due to the workload I doubt that my recovery between shifts was probably enough to fully ‘recover’. And so I crawled to the start of my two weeks off. My period of recovery.

And for the first 3 days I slept. Then ate. Then sleep. I was in desperate need of recovery!

I was, in essence, trying to refuel the body and rest the body and the mind. Perhaps it’s because I’m a scientist by background before I became a doctor but to me this was an incredibly important process – not least to have some time away from baby vomit and screaming children – but to allow me to process all that I had done, seen and learned in that stretch of paediatric shifts. To put it in another context, just like when going to the gym and lifting weights, it is the during recovery days afterwards (not the days you lift weights) that the muscle recovers, repairs and grows.

So there we go; Recovery has been a huge focus for me during the past two weeks (and of course yes, I didn’t need that long and indeed I had a little holiday within that and got tasked with plenty of DIY jobs!). Now though I am ready to return to the frenzy of paediatrics, get my hands dirty, learn, experience and keeping moving forward with, for now, a refreshed body and mind. How do I know this? Well because I miss it, I’ve had enough lying around and now I want to start growing as a doctor again.

So I guess my message to you is this – yes, recovery in our busy modern lives can often get left in our blind spot of life – but please try and make sure you ask yourself from time to time – am I giving myself enough recovery? And if the answer is no, then find a way to weave some more into your days. Every little counts. 

Have a great week. 

Nick 

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 Mystery of the Hole in My Lung: The Doctor Becomes the Patient!

It was precisely 20 days ago that I was at work. It was a Monday morning and I had just finished a busy weekend admitting medical patients from A&E. The Sunday was slightly trickier than usual – I felt like I’d slept in a funny position and my right ribs ached. Still, nothing like a steady stream of patients to focus the mind, and so on I cracked for the 12 hour shift. That night when I got home, however I could hardly breathe. Bent over double on the bed, panting like an expectant mother, I looked to my girlfriend with a glance that said “What the hell is all this about!” I am after all a fit, young(-ish) 32 year old with no medical issues. After failing to convince me to go back to A&E at 1am that morning – my argument being that I’d just spent 12 hours there and I am under no circumstances going back tonight – some knock-me out painkillers, shot of whisky and the classic of all medical inventions – the hot-water bottle (thanks, Mum), I fell asleep….albeit with a breathing rate of 30 per minute.

The next morning things were no better. Being the stubborn mule I am, I still refused to go to A&E – after-all we were short of team-members on the ward. Sadly however, once my registrar saw me hunched over like Golem from Lord of the Rings, puffing away at 30 breaths a minute, I was sent packing down to A&E. I had failed.

Now there are not many perks to being a doctor. With that said, that Monday three weeks ago, I was exposed to one of the greatest cornerstones of the NHS – comradery. You see as soon as I wondered down into A&E, had a quick word with the A&E registrar on the shop-floor saying that I needed an X-Ray to exclude a collapsed lung (that, since I am tall and skinny – well I prefer athletic! – a spontaneous pneumothorax was the most likely cause of my breathlessness), I was whisked into an A&E cubicle. Over the next few hours I had seen 2 A&E consultants, 2 A&E registrars, had a chest X-ray and CT scan, been squeezed into a respiratory clinic that afternoon to be seen by a Respiratory Consultant, and had the on-call medical team drop in to see if there was anything they could do. I was utterly humbled by the togetherness and sense that within the NHS, we look after each other. Now I say all the above not to anger people – and I appreciate some may dislike the fact that I had what is, yes, preferential treatment – but these people whom saw and treated me where my colleagues (for I had spent 4 months working in A&E) and my friends. Throughout the entire process, I spent my time wondering how I could repay them, to show my gratitude for their timeliness in treatment and kindness.

Now not one to be a debby-downer on the situation, let me tell you my two highlights of that day spent in A&E, CT scans and outpatient clinics. The first was the utterly bemused look on one patients face who saw me donned with a cannula in my arm, hospital gown on, being wheeled down the corridor – for I had been the doctor who had treated him only the night before! The second musing was the locum puzzled nurse (who didn’t know I was a doctor) who came in to see me in the A&E cubicle to insert a cannula, only to find me with my own stethoscope listening to my own chest, before defiantly stating that I will insert my own cannula thanks – though as it turns out that isn’t so easy, so I had him do it in the end. Being a patient was a huge eye-opener – you are devoid of control – something that as a doctor, I have a lot of. It brought a definite new respect for what it is like to be a patient. Plus, cannulas bloody hurt!

Anyway, we digress. It turned out that I didn’t have a collapsed lung. In fact it turned out that I had a 2.7cm hole in my right lung – described as a cavitating lesion. Now it is fair to say that this came as a surprise to the A&E team – and to me. What can cause a cavitating lesion like this?  Well, many things including infections like tuberculosis or a fungus. And yes, cancer can as well. This latter diagnosis kept me up for a few hours on that first night I got home befor, at around 4am, I decided that I should stop being an idiot – a 32 year old man who has never smoked, has no risk factors and no other symptoms of malignancy – does not have cancer. And so I put it from my mind from then on.

CT

[CT Scan]

The initial X-Ray

[Initial Chest X-Ray which we expected to show a collapsed lung)

Of course we still didn’t know what it was. The reward for not knowing was an investigation called a bronchoscopy. This is a way to look into the lung and take some tissue to look under a microscope. Now the best way to describe it is this: picture sitting upright in a chair, a little drunk, and then having someone funnelling a slowly leaking hose-pipe down your windpipe and your lungs….all while telling you to “just relax and breathe” in a tone that would be a hit in any yoga retreat. Let me tell you, it is NOT possible to relax…and as for the breathing…well, you feel as though you are drowning. Thank God for midazolam. It was fair to say this sedating drug did its job – I didn’t even recall the first conversation with the respiratory consultant after the procedure.

Post bronch

[Post bronchoscopy – Oh course, I have no recollection of this picture. Bad hair day..!]

Of course from that day that I went down to A&E to get that ‘quick’ x-ray, I have not been back at work. Why? Well, if I did have tuberculosis, I would be a huge infection risk – particularly as I am now moving into paediatrics – and those little people have far weaker immune systems than you or I. As such, while the hospital doctors that are treating me wait to see what bugs grow in the Petri-dish to see if it is tuberculosis or something else, I have to be at home.

Three weeks at home may sound like a luxury. It was hell. I felt a fraud, lacking in purpose, lost even. You see I felt well in myself after a week of antibiotics and guilty that I wasn’t at work. It made me realise how much I value my job as a doctor, how it is part of my identity and that I love that. I am after all, proud of being a doctor and working with such brilliant healthcare teams. Although, it is true that I became a very good house-husband over that time, the itch to return to work never left me. And finally after three weeks of waiting and waiting, I have finally been given the all clear to return.

After all that has happened, two questions do still remain: what IS that hole in my lung? And how can I possibly thank all the people that cared so much for me while I was converted from the doctor to the patient.

Only time will tell…

Nick

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