My Weekend

Being a perfectionist by nature, I find it highly unsatisfactory when I am forced to do a job more shabbily than I would have liked. Last Thursday was my first proper day in the new job, so I wasn't too bothered that things didn't run as smoothly as they could have (had I had a computer password and known where various items such as tongue depressors and growth charts were stored). However, I was surprised to find that it was just me and one junior covering both the inpatients and the acute admissions, on a weekday. The junior (a house officer) was being used by the consultants as a one-man phlebotomy service for outpatients at the same time, with me having to step in for the 'difficult' veins. This meant that many routine jobs for the stable inpatients didn't get done until late in the afternoon, and waiting times for the admissions were dreadful.

How naive of me then, to imagine that the weekend would be any better (I reasoned that without the outpatients, I would have the house officer to myself). Saturday arrived, and as I started the ward round, I wondered aloud how the house officer could be so late. "There isn't one on weekends," said the nurse. The consultant wandered in to join me for a few patients, but then got bored and went home, because none of the patients was critically ill. "Call me if you're worried about anyone," she said. So that left just me, to finish the ward round, do all the jobs, take all the referrals and see all the admissions. Naturally things were going to be less than optimal. So I did my level best, and I am confident none of the patients came to any harm. But I did lose my rag at one point and snap at a mum who demanded to know why I hadn't come back with her daughter's blood result yet. Then I felt really guilty for being rude. I'm fed up with being human.

I'm also fed up with working weekends, that was the third one in the space of one month! And then this weekend when I am finally off, Mark is working. I hate my life.

Grump

):

Sad

Spot of comedy on the Saturday morning ward round: nurse opens baby's nappy and lifts its legs up to change it, when the baby explodes! There is poo on 3 of the 4 walls of the incubator, while the (arguably rather cute for a 30-something weeker) baby lies in the only clean corner, looking brightly about her as if nothing has happened.

Well, I'm out to the shops (not that I need anything) just to be out in the sunshine (a rarity in these parts) as I go onto night shifts again tonight. Night shifts are RUBBISH - they ruin your physical and mental health and destroy any semblance of a social life you had before. I am sure they could also quite easily destroy a marriage or a family. In fact, I think perpetual night shifts would be a brilliant form of torture.

Tomorrow's weather

High
10°
Sunrise: 08:45
Chance of Precip. 80%

Depressing. So there I was on a downhill (having peddled up it on the way to work), having to peddle furiously to keep moving, because a fierce headwind was blowing me UP the hill.

That's part of the reason why I got a car. The other reason was that there's a stretch on the way to work where the cars join the M77, and also a roundabout where the drivers don't seem to look left before turning off. (partly due to the small number of cyclists, so it's a bit of a circular argument)

What I really need though, is not my car back, but some sunshine!

hopeless junior docs

I knew it was going to be a struggle when she said "so you don't suction them before drying them out, then?"
[trying to upload a few things to my 'eportfolio' but it's painfully slow, so blogging at the same time to alleviate my boredom]
Any final year medical student worth their salt should know that resuscitating a newborn baby begins with drying them out with a warm towel - because that's most often all it takes to stimulate breathing and crying. Most newborns can clear a few hundred mililitres of fluid from their lungs in a matter of minutes. And drying them out so they keep warm will keep the lung surfactant working.
Yesterday was a complete nightmare. Having spent the whole of Saturday in super-patient mode with a brand new SHO (comforting myself with the hope that Sunday would be better), I then get a different, totally new person on Sunday. Even worse, she's never put an IV line in a child before, EVER, and knows less than a medical student about how to resuscitate a baby. So I end up doing everything (and I mean EVERY SINGLE THING) myself. For 12 hours. And because I'm painfully aware that I'm meant to be teaching her, I page her and wait for her to swan in to observe what I am doing before I start each task, slowing things down even more. So over the course of the day, I did all the IV lines, all the blood samples, saw all the babies on post-natal ward the midwives were worried about (including admitting and performing a lumbar puncture on one who was septic and comforting its tearful mum), attended all the deliveries on labour ward requiring a 'paediatric' presence, took referrals from community midwives, did all the 'jobs' on Special Care, and kept track of (or tried my best to keep track of) the 2 Intensive Care babies. Lunch didn't happen (I didn't expect it to). There weren't even any horrid cheap chocolates from well-meaning relatives on the nurses' station to keep me going. I drank so little fluid that it didn't matter that there wasn't any time to go to the loo. By the end of the shift I was a complete wreck (but just about managed not to show it). Then She left before I did, which I think is just rude. This is why I'm often grumpy and impatient when I get home.
I was so tired that I slept until noon today. And I'm on call again tonight, with another brand new junior. I don't expect them to be 'good' at the job by any means, but it would just be nice if the inexperience was tempered with some enthusiasm. It just becomes a bit ridiculous when I not only have to perform the task they are unable to do, but they can't even be bothered to come and watch and learn.

Are extroverts better doctors?

I seem to get a lot of comments that I 'lack confidence', even when I've just been doing something I'm extremely confident about (e.g. making a presentation on a topic that I've researched thoroughly, and fielding all the questions quite easily). Perhaps it's a cultural thing, or, more likely, a personality thing - I don't speak loudly ever (noisy people really get on my nerves), and too much eye contact makes me feel really uncomfortable. I don't do physical contact (e.g. arm over the shoulders to comfort bereaved) with strangers, either. I don't like resuscitation situations, because you have to shout to be heard, and I can come across as uncertain if there is even the faintest doubt (e.g. about a patient's prognosis).

But does being a quiet, introspective person make me a bad doctor? In the patient's position, I'd much rather have a quiet doctor who considers things carefully than a brash charlatan. I'm also more of a writer than a speaker. What I'd really like to be, eventually, is a medical journal editor. But it seems that in order to get there, I have to temporarily (for the next 5 years or so) become some extroverted, over-confident person that I am not.

Black Thursday

It's never a good day when you arrive at work and everyone's scurrying about trying to deal with the aftermath of a dead baby - distraught parents, the missing Death Certificate pad (doesn't get used that often), where to put the body, seeking consent for a post-mortem, self-blame, and groggy, grumpy consultants (from being dragged out of bed at 5 in the morning).

But two deaths in one day - now that's almost turning into adult medicine. Baby A was admitted to the special care unit with hypoglycaemia. That resolved with nothing more than a bottle feed, but as he was sucking poorly, he had a nasogastric tube passed, and was fed hourly through that. All seemed well until 6 o'clock this evening, when he was found ashen and lifeless in his cot. The midwife immediately pushed the cot round to Intensive Care, and raised the alarm. I was in the next room, and was soon at the bedside leading the resuscitation. We bagged the baby and started chest compressions as his heart had stopped too. I intubated him fairly easily, and was able to get good chest movement. He had no IV lines in (he had been so well) so we gave him adrenaline through the tracheal tube. We even got a cardiac output back for a few seconds. But after half an hour (with one of the midwives trying to phone the consultant at home) it became clear that we weren't winning. So we stopped. That was actually the first time I've ever called the time of death in a resuscitation (belated, I know, having been working for 4 years) - being a mild sort of character, I usually get sidelined in these kinds of situations.

Then came the grim task of speaking to the parents. I'd never done that before (though have seen it done) either, not even with one of those crappy actors they hire for clinical exams. I decided to be direct. I started with the classic "I'm sorry, but I have extremely bad news" then said (after a calculated delay), simply, "your baby has died". I described briefly the (arguably heroic) measures of the resuscitation, and how they had unfortunately not succeeded in bringing the baby back. They cried. The midwife hugged mum and offered her some tissues. We just sat for a while, then I said I would leave them alone, but would come back at their request if they had questions, and encouraged them to come and see the baby.
It went OK, I suppose. I've been told (by a consultant paediatric oncologist) that if you're breaking bad news and you don't get a suitably negative reaction, then you aren't doing it right.

SHO quote of the week

"They always look so disappointed when they come out."

Insightful observation about newborn babies by my FY2, while drying out a new arrival. The response, of course, is "wouldn't you?"

"Hey man, this is yours"

...actual words uttered by my junior as he handed a newborn baby to its father. As if he were perhaps returning a borrowed football. The new father, on the other hand, was too busy fighting back tears to notice the inelegant handover. It was coming to the end of a long night shift, and the midwife and I struggled to keep from laughing out loud.

The new job's OK. Once again it's horribly anitisocial hours (2 weekends in a row; 4 long days in a row), but the work itself is fairly satisfying. I think I have finally grown into the 'middle grade' role - being responsible for making decisions about patients on the ground, and accountable directly to the boss (consultant). I feel like I know what I'm doing, and that I'm doing it well. Frighteningly, that was not the case in my last 2 posts, and I struggled with my seeming inability to perform better than (or even as well as) others on the same rota at work.

..have to go. More next time (as am on normal 9-5s this week - amazing!).

Poo

...so while Mark is away in Malawi saving/improving the lives of poor African children, here I am in Edinburgh, joining in the fight against....childhood constipation!
Ok, so I also admitted a baby with likely viral meningitis, and a boy who'd had a prolonged seizure. But the second-last patient of the day (in A&E!!) was a 2 year-old with constipation. "She won't eat any fruit and vegetables, doctor," said Father. *Lily hadn't been to the toilet for a week, and when she finally went, she passed "a golf ball", unsurprisingly causing her much distress. After checking for any birth/neonatal/developmental/family history to exclude a pathological cause (e.g. Hirschprung disease, hypothyroidism, neurological causes etc), I gave him the old "it'll take as long to clear out as it did to build up" talk, and went to fetch some Movicol and a "constipation pack". The fact that these ready-made packs exist, particularly in the A&E department, does amaze me somewhat. They contain a leaflet about healthy eating, a booklet with a cartoon Mr. Poo, a Bristol stool chart and diary, and a bottle of bubbles (for toilet time amusement). I hand it to Lily's father, explaining the use of the chart and diary, trying my best to be sympathetic. This is why I didn't like community paediatrics much.

keep praying

The exam was a bit of an anticlimax. After months (and I mean HOURS AND HOURS AND HOURS!!!!!) of preparation, I think I may have exterminated myself on the "video" station. I spent some time on the train back from Newcastle calculating the worst possible and best possible scores, and I think (with a pass mark of 100/120, i.e. 83%) it's going to be a very, very close call. Either I'm going to pass by a couple of marks, or I'm going to fail by the tiniest of margins. So I'm not crying YET. Please let the examiners be kind to me.

The other side of the fence

[24 hours to my exam]

Reading over recent entries, I realise it would be easy to suppose that I am becoming callous (or trying to be) in order to cope with emotional overload. The truth (or part of the truth) is that writing well about one's emotional response to a situation requires one to at least partially relive it. And sometimes that is a luxury I just can't afford. (e.g. when I need to ram hard facts into my memory for the exam)

On the other hand, I have been fascinated of late by the writing of Patient bloggers, such as Tiffany C. I can't remember anymore how I stumbled upon her blog, but it remains one of my favourites. Some entries, such as this one have been particularly helpful with my own approach to patients who are growing up with chronic illness.

The problem, of course, is that not all patients (or parents) are quite so articulate. Being a doctor is sometimes a bit like being a translator. Say you are explaining to parents something like a new diagnosis of Down Syndrome. You have about 20 seconds to assess their vocabulary (medical and non-medical) and likely desired level of detail, as well as their emotional response. If the admitting doctor has taken a detailed social history (e.g. parents' ages and occupations) then you have a leg up - but it can still be risky to assume things.

beyond the pale

[4 days to my exam, so please excuse the poor writing]

We got off to a poor start: I introduced myself, full name as is my custom, and stating that I was the registrar on call. "Our 6 week-old son was in a month ago," the mother said, hoping that I would recall the episode, which must have been pretty harrowing from their point of view. "Maybe you saw another doctor," I said. "No, it was you," she said, certain. "You did a lumbar puncture." I still had no recollection. It must have been during my last stint covering A&E, when I had a run of 'septic' babies (3 or 4 of them) who all needed lumbar punctures. "How is he now?" I asked, hoping to fix things a bit.

Meanwhile, *Mairi lay languidly on the examination couch, her pallor so extreme that she seemed almost transparent. "The doctor said she was anaemic," said her father. I thought that must be the understatement of the century, but decided to get the details straight: "he's done a blood test?" "No, he was going to do one in 3 months."

This was all a bit surreal. Extreme pallor in previously well child, no symptoms apart from 6 to 8 weeks of lethargy (i.e. no source of blood loss). Diagnosis= most likely bone marrow failure= either aplastic anaemia (autoimmune, post-viral etc.) or leukaemia (or other haematological malignancy). In plain English = VERY BAD SIGN

The A&E doctor had managed to get just enough blood for a full blood count.

[argh have to get back to my revision]

Anyway, to cut a long story short, the blood count showed almost no white cells, one blast cell and a haemoglobin of a third what it should be. The consultant haematologist who'd looked at the film came down to A&E in person to give the parents the likely diagnosis, and explain that she would need to take a bone marrow sample to confirm the diagnosis, and that Mairi would have to be admitted to the Haematology/Oncology ward. At that point, father responded with a rather loud "F***!"
Dr. T remained calm; in fact, she said "yes, that would be my thought exactly." This was a good lesson for me, because the last time someone had sworn that way, I was explaining to a father that his daughter had pneumococcal meningitis. And I had presumed his swearing was directed at me; perhaps I had broken the news insensitively. That plagued me for a couple of months. But I knew Dr. T had done a good job. I guess some people just respond that way.

Anyway, back to Mairi. So she was admitted, and had a blood transfusion. I haven't been able to catch up with the rest of her story yet (she's now under Dr. T's team so I haven't seen her).

Middlesbrough

Am writing this from a hotel (motel?) room in Middlesbrough where I am at a Neonatal Conference. (I love my 3G modem!) I have to say, it's not been particularly inspiring so far. I was hoping that it would make Neonatology make more sense at least. My impression beforehand was that despite the surfactant trials being poster child for the Cochrane collaboration, Neonatal medicine was largely witchcraft. Unfortunately, my suspicions have been confirmed. Take phenobarbitone as an antiepileptic in neonates, for example. Phenobarbitone is an old drug (brought to market in 1912). And even when given with a second anticonvulsant, it only stops about 60% of babies fitting, and is not without side effects. Yet it is the best thing neonatologists have for treating convulsions in newborns! What on earth have all the researchers been doing?! The other thing that got my back up was the talk on Science and the abortion debate. Now I signed a petition and wrote to my MP, as a member of the general public, in order to try and influence the parliamentary vote on this issue. The talk was given by a Professor who had been on the advisory panel for the MPs debating the Human Fertilisation and Embryology Bill. Yet he didn't seem to have a personal opinion on the issue at all; he seemed determined to remain neutral. I think such responsibility is wasted on people who don't have a clear system of personal ethics. A Neonatologist should be duty bound to be an advocate for his patients (or potential patients). I would have been less angry had he picked a side; pro-life or pro-choice, I don't care, it was his neutrality that was irresponsible.
Among all the (apparently) big names in neonatology at the conference, I can't help but feel like a teenager indignant at all the 'grown-ups' for messing up. It seems they have got neither the science nor the ethics sorted out.

23 May; posted in retrospect

Bizarrely enough, the reason I've not been writing lately is I've felt a little saturated by the number of other people's stories I'm carrying around in my head. When one first assesses a patient, one "take[s] a history"; obviously this information then forms the basis of the examination and any further tests, and is duly recorded in the patient's notes. What the doctor is then supposed to do with the residual information impinging (sometimes rather disturbingly) on his own thoughts by the end of a 12 hour shift is slightly less clear. It is too easy for others to say, "go home, switch off, do something to relax." 4 years into working life, and I am still struggling to find a balance between empathy and detachment. Sometimes I feel physically sickened by what I've heard and seen. And then I get home, and I can't relax because I've got a clinical exam to study for! I have to read up on the conditions I've seen, and memorise the symptoms and treatments etc because I'm going to be tested on it all in a few weeks. I do go swimming or running or something if I'm on a short day ("short"= 9am to 5pm), but long days or nights (9am/pm to 9pm/am) make even this impossible. The only thing left that is vaguely soothing is doing the ironing; something about the creases coming out, I think.

One thing I learnt on nights last weekend:
A one-year old girl had come into A&E with a short history of poor feeding, crying all the time and her body being "so stiff, it was hard to get her into the car seat". Although her temperature was only 38 degrees, her behaviour (the obvious irritability) made it likely that she could have meningitis. She was otherwise pink and well-hydrated, and her condition was stable. I explained the situation to her parents, and explained that I would need to perform a lumbar puncture. They flatly refused, but did agree that she should be admitted to hospital. I couldn't leave it, so, feeling rather pathetic, I rang the senior registrar. She spent a few minutes with them, then emerged, saying, "get the LP trolley, they're fine with it." "What did you say to them?" I asked. "I said they would never forgive themselves if it turned out to be meningitis and we missed it," she said. Nothing like a spot of emotional blackmail to save the day.

"Monospots are rubbish"

We've had a run of patients with large neck glands (cervical lymphadenitis) in lately. The first, a 16 year-old who presented with a sore throat and dehydration, had obvious glandular fever. Her glands were so large, her chin had nearly disappeared into her neck. The tonsils were red with exudate, and her liver and spleen were enlarged. Her lymphocyte count was 26. She had a positive monospot (unsurprisingly).
Last night's crop of new patients included a 7 year-old with a left-sided painful neck swelling and an 8-month old with a non-tender 2cm neck lump. Both patients had had monospots sent, to which the consultant said "but monospots are rubbish anyway." So I thought I'd look up exactly how rubbish they are.

I found this on Medscape:

its sensitivity is only 20% in young children. This test is frequently used to assess EBV infection in older children (>5 years-old). It is easy to perform and has a sensitivity of 85% in older children and a specificity of 97% (Peter & Ray, 1998).

here's a more complete answer
ok now i'm bored.

Notes 1

4 day old; unbooked/concealed pregnancy; both parents IVDUs known to social work; NAS on oramorph
reading: associations with maternal drug use: defects including cardiac (esp cocaine), abdominal wall (these associated with SGA baby/placental insufficiency); polycythaemia and increased risk of neonatal thrombosis;
7 month old; bronchiolitis. Both parents smokers.
reading: associations of paediatric respiratory disease with maternal (fewer data available on fathers) smoking; increased incidence of URTI and LRTI including otitis media, pneumonia; risk factor for asthma development

[note confounding factors: J Am Board Fam Pract 14(5):330-334, 2001 - mothers who smoked during pregnancy likely to be younger, and have smaller babies of shorter gestational age; I'd guess they would be of a lower social class also.]

Note the former baby's future does not look particularly bright. But that is another story for another time.

Chatted with Prof I met at conference - advice on how to proceed re: getting into some Proper research. Also with sensible consultant on for Receiving this week, which makes a big difference. Am liking work more this week.

Fed up already

I've never hated work quite so much. Two days back at work, and all I am looking forward to is my next day off. Am hoping it is just the fact that this is Acute Receiving, and I chose the placement specifically because I have less experience in the area, hate resuscitations and the aim was to get it out of the way. But I'm hating it even more than I thought it would. I hate how patients come through, you fix them if you can, refer them on if you can't, and then you never see them again. i.e. there's no continuity; the patients never feel like your patients; it's all just really fragmented and everything takes twice as long because it's impossible to know all the patients. And everyone else seems to be off sick all the time - I acceded to a "request" to cover someone's evening shift yesterday. But I really really wanted to say 'no'.

So I've booked myself a place at a research conference. I hope it's good. Am desperate at the moment for some inspiration; something to remind me that there is more to medicine than unthinking drudgery and ungratefulness from all sides. Otherwise it will be time to start plotting a way out.

A short break in Barcelona

[Click picture for more]

The Toast Sign

The first time I came across the Toast Sign, I didn't recognise it. I was a medical student on the labour ward, fascinated by the sight of nursing auxillaries scurrying about with trays of Tea-and-Toast - only for the mothers who had already given birth, of course.

On call yesterday at A&E, I was asked to see an 8 month-old boy who had come in with vomiting so severe, the A&E doctors thought he might have intussusception. As I approached the curtained cubicle, I heard little crunching noises. Behind the curtain was a pink and rather cheery-looking baby, chewing on some dry toast with his brand new teeth. "He's miles better since they gave him that fluid through the drip," said his mother. "He's back to his normal self," added father. I sent him home with a diagnosis of gastroenteritis.

Fluid balance charts on childrens' wards can often be quite informative. For instance, one of the more bizarre but common breakfast choices on our ward is a packet of Quavers . But you can be sure your patient is very nearly well enough to go home if they've had toast. Especially if they were admitted with tonsillitis. But it also works for patients with pneumonia or even orbital cellulitis. I think I might be on to something. Christmas BMJ here I come.