tired beyond description

..have just wolfed down the bagel I got up early to make for my packed lunch - finally, at 10:30 at night! This is the first time I've sat down today for more than 5 minutes without being harrassed from all sides. On the face of it, working 13 hours without a break doesn't seem so bad. But I am tired beyond description. The physical tiredness I can handle. The parched throat and unsettled stomach I can put up with too. But I feel as if all my emotional reserves have been sucked dry. On my way out of the hospital, I got stuck behind 2 porters pushing a large metal laundry cage. It seemed as if they were sneering at me and purposely pushing it just that bit faster than my weary feet could carry me. They laughed, and it was cutting, as if the joke was on me (perhaps it was, but I'll never know). I just burst into tears, right in the corridor, and cried uncontrollably for half an hour. I can't explain it, except that perhaps my usual emotional 'buffer' had been chipped at all day by demanding patients and nurses, and now there was nothing left, the smallest slight could make me crumble.

It wasn't even a bad day. Just madly busy. Apart from my usual ward duties, I saw 8 patients in A&E on my own (normally there is a senior doctor around) - each had to be worked up as if for an operation, bloods taken, IVs started, X-rays ordered. Patients with appendicitis can be particularly demanding - what is technically a very simple clerking is complicated by the fact that the patient is young and has usually never been in hospital before. (and therefore naive to the embarassment, prodding and sticking-with-needles that a hospital admission entails). The patient expects empathy, but not too much. It is quite demanding to project the right balance of "seen it all before, doesn't rattle me" and "of course I care that this is awful for you".

I failed to pass a catheter in a man who was in urinary retention because his penis was blocked off by blood clots. He was literally delirious with pain, but I didn't want to force it (you can create a false passage if you ram it hard enough). "Do you mind if I get up on my feet?" he asked, struggling to right himself with the rails of the bed. "You've only got one foot, dear," nagged his wife, as if reminding him of a forgotten hat or keys. The man had had a hindquarter amputation several years ago, and could barely sit up without assistance. It would have been comical if it hadn't been so sad.

I also put scalpel to skin for the first time today (previously I've only ever stitched things together), to incise and drain an infected sebaceous cyst (i.e. massively oversized pimple) on someone's back. Nasty. But kind of cool.

So it wasn't a bad day. Just a day with a week's worth of work and a month's worth of emotion packed into 13 hours. And no time for food, rest or even water. And the guilt of handing lots of stuff on to the on-call night team. And the guilt of having made people put up with pain, just because I can only see one patient at a time, even if 3 arrive at once! (And plenty of nurses to rub the guilt in.) Right, should get washed and to bed - must be up for work again in 7 hours. Think am so exhausted am becoming slightly euphoric.

why there aren't many women in urology

...too much male anatomy. man of 40 attended A&E with a fractured penis at 6a.m. "I woke up with an erection and rolled over, and I heard - or rather, felt- a click", he said. "This was followed by rapid detumescence" reads the admission clerking. There was a large black bruise on the side of the injury. Whatever the story, he was soon taken to theatre, where the skin of the penis was peeled back, and the rent in the fibrous tissue sewn up.
the morning ward round involves lifting up too many gowns and finding horrible swollen, bruised and variously deformed phalluses. its enough to put you off men for life.

day 5 on urology

-had to bleed all the patients myself because the phlebotomists appear to be on strike
- catheterised a man with a leaky bladder - i hate it when patients ask "have you done this before" i mean, do they think i do this for fun?
-went to theatre to watch D and JM operate - or in other words saw a man transformed into a scrotum by sterile drapes and then sliced open, a gleaming cyst removed, and sewn back together again

i love my job

i love my job
i love my job
i love my job

what can i do to convince myself that that is true? anyone in a full-time job (duh, hence the term) spends so much of their lives working that there must be more to it than a means to an end (i.e. payday). or do i expect too much out of life? perhaps it is routine that dulls the magnitude of each day's accomplishments. i suppose one could say that i helped save someone's life today - 70 year old woman, speaks only Hindi, suddenly becomes short of breath and manages to convey that she is suffering from some chest pain. admitted over the weekend with abdominal pain and vomiting, she is normally on a full compliment of cardiac medication - generally bad news for any patient on a surgical ward. at 11 o'clock - when all the senior doctors are safely away at theatre or in clinic - she starts gasping for breath, goes cold at the peripheries, her distended neck veins pulsing to her ears. that is pretty much what greets me when i get to the ward - i have already asked over the phone for her to be sat up and put on high flow oxygen. she is attended by a student nurse, who helps hold her up while i deftly slide my stethoscope in to listen over the lung bases. she has fluid nearly up to the top of her lungs - in other words, she is drowning in her bed. i order an urgent ECG and some IV frusemide. i've read it in the books and have even seen it done, but this is the first time i am running the show. the presence of the woman's daughter is a mixed blessing - she translates the patient's panting half-sentences, but her presence gives me a tinge of stage-fright. i feel compelled to keep explaining what i am doing - whereas if all i had was an obtunded patient, i could just get on with it. in the mean time, i despatch the student nurse to call the medical SHO. by the time he arrives, everything is under control. the patient is chatting with her daughter, as best she can with the oxygen facemask still on. i guess it was quite a satisfying experience, but it is one that i will soon become used to, and then it will be "all in a day's work" as they say.

am on call again tomorrow. i called in sick for the first time ever today. it was a difficult decision because i felt absolutely dreadful (and was arguably a public health hazard) yet i didn't want to be seen as skiving, particularly as i had been on holiday all of last week. i suppose it is quite ironic that i should have fallen ill while on leave.
it is now evening and my cold is much less fulminant, my head clearer for having slept for much of the day. i was amused to overhear the cleaners going "sshhhh, she's sleeping" in loud stage whispers outside my room as i sat in bed reading. my day of reading (last 3 issues of BMJ, verses from the Bible, last few chapters of The Life of Pi, photography magazines) and dozing has been much more refreshing than my trip to york. in fact, my holiday left me with an inexplicable feeling of emptiness. i barely finished 2 rolls of film (on a usual holiday i easily burn a roll of 36 a day), the 'therapeutic massage' did nothing for me (i am too self-conscious and ticklish), and the guilt that followed the purchase of a new winter coat made me determine not to spend any money on myself for a long time to come. perhaps it was a good holiday in the sense that it made me long for work again?

I love meeting people, and I love a good story, particularly one with vivid description, in the vein of Garcia Marquez. it may seem that medicine and stories don't have much in common, but in fact, a good story is the basis of all diagnosis and treatment. as a doctor you are privileged to obtain from the patient their most intimate details - bowel and sexual habits, what the voices say, what their grandmother died of and so on, and your job is to arrange them to form a coherent story, or 'history' as we say in medical parlance. and, of course, your very listening to the story is the beginning of the patient's treatment. despite all the attendant pressures, i like the role of 'doctor'. outside of work i can be a bit of a social misfit - it can often be a strain to so much as ask a stranger's name, nevermind finding out things about them. but in the hospital i can nearly always say the right lines with confidence. perhaps that is what i miss when i am on holiday.

postscript:
Mr. K was eventually discharged with a diagnosis of Munchausen's syndrome.

i thought that by the time i was a doctor i would have acquired certain 'doctorly' attributes - such as a high tolerance for other people's nonsense, and a certain generousity of spirit - but i'm still the same lousy person. i still get grumpy from missing meals, annoyed by cry-babies (particularly strapping young men who whine when you stick a tiny needle in them), and invariably feel emotionally and physically drained at the end of a 13-hour shift. i get through only one in two on-calls without ending up in tears at some point. sometimes it seems that being 'professional' means everyone else is allowed to be rude and unfair to you and you just have to absorb it all.

in order to cope with the prospect of having to do it all over again, i run the day's events over in my head, milking them for the 'good bits' - patients who've made me smile, and things i've learned. yesterday's favourite patient has got to be Mrs. D, an 89-year old retired nurse who had come in again with a prolapsed rectum. As she lay on her side with my gloved hand between the cheeks of her bottom, she said "i checked what day it was, in case you asked - they always ask me what day it is when i come to hospital." i had to smile. 'what day is it?' is one of the questions in the mini-mental test.

Mr. G was delirious with pain from a bladder distended nearly up to his chest. i inserted a catheter, which promptly yielded a litre and a half of urine - as much as most people produce in 24 hours. "Do you mind if I quote Shakespeare?" he said. I was quite startled to hear him speak as the only sound from him since his arrival in A&E had been a constant unintelligible groaning. "Nope, go ahead." "For this relief, good thanks." he grinned - as far as he was able to grin with his top dentures missing.

the most intriguing patient of the day was Mr. K, a middle-aged man with an unplaceable accent. he was pale and drawn and doubled up with pain when i found him. i wrote him up for some pethidine. "i've had 6 laparotomies in total", he said, "it all started when i got stabbed in Warsaw last october." Even though he claimed to be an engineer, he used lots of medical terms like 'laparotomy' and 'venous cut-down' and his story was either extremely tragic - or just poorly made up. I always work (on principle) with the patient's word as truth, but the consultant, Mr. A, didn't believe the man for one minute. the abdominal x-ray did, however show that he had drunk some contrast medium recently, which fitted with his claim to have had a CT scan in Poland last saturday... we admitted him and instructed the nurses to monitor his blood pressure closely - an excuse for checking on him hourly. it's all very bizarre.

Just as i was about to leave (45 minutes after i should have gone), i was bleeped by one of the wards. "Mr. L's family would like to talk to a doctor," said the nurse, "they want to know what the biopsy results showed." This was a patient i had done lots of running around for - i had organised an urgent CT scan, phoned the histology secretaries twice for the biopsy results, badgered the bed manager to get him moved to a surgical ward, and persuaded the social work department that they needed to get involved. after 11 hours on my feet in A&E, i was tired and not in the right frame of mind to be sympathetic. but somehow i gathered the last remnants of something - perhaps it is the very stuff a doctor is meant to have. i asked the nurse to put the patient's daughter on the phone. "they took 3 small tissue samples from his stomach, and none of them showed any cancerous changes. now this doesn't rule out gastric cancer, but it does make it more unlikely, and it means that all the tests we've done do not seem to point to cancer as the diagnosis. Mr. M has referred your father on to Mr. A, another surgeon who specialises in diseases of the stomach, so he is under the care of the best team to treat the problem." what i really meant was, "we don't know if your father has cancer or not because none of the tests has actually shown anything. and ask to speak to Mr. A's house officer next time." but she seemed to buy it. "thank you doctor."

one of the more bizarre things about about working at the weekend is that you look forward to Monday. Monday, when everyone else will be back so I don't get bleeped every 5 minutes by 4 different wards AND have to see all the surgical patients in A&E. Monday, when I get off work at 5 instead of 9pm. When the ratio of anxious relatives to doctors is not something like 50:1 - that '1' being me.
having said that, speaking to relatives and explaining things was one of the more enjoyable tasks over the weekend - people seem fairly grateful to be told anything - even if I had never met the patient before saturday and was making half of it up.
saturday was madly busy, but sunday merely seemed to drag interminably - talking to and examining patients, sticking people with needles, inserting catheters - until all the white-haired men and paper-skinned women blended together. Rubber tubes up shrivelled penises, a finger in stool-packed rectum, fungating breast cancers - by the end of it you simply cannot look at a naked body the same way again.