Bad news for Mrs. B

"You know what the problem is with Mrs. B?" says Dr. K, in a typical ward round aside "She just sits. Like a pudding." It's not a generous comment, but it is obvious what he means. Mrs., or rather, Dr. B (she is a retired physician) isn't looking too bright these days. We have been trying to explain the importance of her being on warfarin to prevent further strokes. She doesn't appear to understand. The next day, the Physio comments that she has difficulty following simple instructions. "See, a pudding," says Dr. K. I am given the task of performing a mini-mental state examination. She scores 23/30, which is way below normal for her age (late 60s)and level of education. We check the report on the MRI scan she had in May. There are multiple small cortical infarcts - tiny strokes affecting the bits of the brain important for language and calculation. Just in case, we check her thyroid function and folate too. These prove normal. The diagnosis is vascular dementia. How do you tell someone (who is still cognitively intact enough to care)that they have dementia? That they will become progressively less intelligent and eventually become dependent on others for all activities of daily living? How do you tell their family?
I asked her husband if he had had any concerns about her memory lately? Had she seemed 'not herself' at times? He appeared at first to be in denial of the obvious. She did not seem to comprehend - or perhaps did not want to. Until suddenly she said, "so it's not going to get better then? the writing, the counting..." her eyes searched me for some reassurance. "It's not to say that nothing can be done to help things, I said. "Like you can write things down to help you remember, and the Physio gave you a walking frame." We both knew nothing could be done to halt the loss of intelligence, the eventual loss of dignity and self. How awful to feel one's own mind failing, yet have enough of it left to worry about the consequences.

too hot to string a sentence

its 29 degrees and there is no ventilation in my room apart from a wide-open window but the air outside is muggy and still

London on Saturday  

Warning to all would-be medical students

We had 4 sixth-formers on work experience today. And a medical student as well. Unfortunately for them I was in an incredibly foul mood from having worked all weekend. I was particularly abused this weekend by some nurses who had the collective intelligence of a woodlouse. I managed to muster just barely enough niceness for the patients and their relatives, but had none spare for anyone else. It's one of those 'I wish I did Architecture' days. Or any job where you get all your weekends (or at least all your Sundays) off. The warning is this: a career in medicine means you will have to work at LEAST one weekend a month for the rest of your life. This month I have worked 2 out of 4 weekends. No amount of life-saving or gratitude from anyone, or intellectual satisfaction, or money is worth giving up 2 weekends a month for. And that is not to mention how ungrateful people can be. Too many bright, promising young people become doctors through parental/societal pressure, or simply lack of imagination, and lack of effort toward finding out about other career options. So if you are 18 and reading this, consider your options carefully. A career in medicine does NOT give you 1. Money (I get around on a borrowed bicycle and can't even afford a mortgage on a one-room flat) 2. Respect (see previous entries re: rude/racist patients) 3. Intellectual satisfaction (if you want that, become a proper scientist; Medicine is primarily an Art) 4. Emotional/spiritual gratification (on the contrary, most weekends on call leave you emotionally wrecked). What is left? I guess it is the same masochistic gratification that a marathon runner aspires to.

time to move on

last month as a house officer and I am getting thoroughly bored of my job now. Did my first sucessful lumbar puncture this afternoon. Nice clear cerebrospinal fluid dripping out of the hollow needle and into sterile pots ready to send to Oxford. Spilled a little on my trousers. (this is why i always use Bio detergent!) "Ok, it's all done. How are you doing?" The patient replies in the affirmative. "You might get a headache, so we usually say to lie down for the next 4 hours. We'll tell you as soon as we get any results." "Thank-you, doctor."
Saw a lady with haematemesis (vomiting large volumes of part-digested blood) and aspiration (having some of it go down her lung) yesterday when on call. Knew what to do and went through all the motions without really having to think. (Even the talking to the patient and empathising with distraught relatives is second nature. If only dinnertable conversation were this simple!) Organised tests for a patient to go onto the lung transplant waiting list. Wrote up some chlordiazepoxide for a patient withdrawing from alcohol, Piriton for a rash, blood gas then oxygen and salbutamol for a man in respiratory distress. Obtained permission from some grieving relatives for a post mortem on a man with cancer of unknown primary. We've had a load of moribund patients lately and as a result i've had to go to the mortuary a lot too. (it's right next to the canteen, so you drop by to see the corpses at lunchtime) It's all becoming routine. It's a drag to get out of bed in the mornings to do all this stuff all day. How can i be so bored with it all so soon? I'm looking forward to being a bit out of my depth again come August.

"Ah! Brrreathe the Scaaw-Ishh airr!"

My exact thought articulated by a skinhead in a Scotland rugby shirt, stepping off the train from King's Cross. A shower in soft Scottish water, a freshly made bed in a spare room in Marchmont. A sunny day at a cool 20 degrees. A lift to church; kids from creche all grown up. Old friends from university; someone who actually remembers it's my birthday this week. It's like coming home...

And now I'm back in Reading and it's back to work for another 12 days in a row. ):

homework

My first day off after working 12 days in a row (particularly demanding as we've had a run of patients presenting with hypercalcaemia due to cancer of unknown primary - but that's another story) and I've got homework! I've got to do a case presentation on Monday. This is how it goes: 23 year old lady from Zimbabwe presents with a 3-month history of weight loss (10kg), painful joints and muscle weakness. Her only past medical history is a miscarriage two years previously. She had a negative HIV test then. I went down to medical records to get the notes myself, and when looking through them, was amazed at the number of complex tests she had had in the space of about 3 days. My own contribution was arranging an urgent echocardiogram when a pericardial effusion was seen on high-resolution CT. She also had lung function tests, nerve conduction studies and a bronchoscopy. One ward round entry states "patient exhausted after today's investigations". The eventual diagnosis was of mixed connective tissue disease. In addition, an HIV test was positive. So the second bit of my presentation is on HIV and autoimmune disease. A quick look on pubmed reveals that this is in the 'case report'/ J Exp Med realm (i.e. vanishingly rare/ newly noticed). Unfortunate for the patient but pretty fascinating stuff re: T cell suppression etc. Takes me back to my BSc year - probably the last time I actually had to use my brain (day to day medicine is pretty brainless). I miss that.

minutiae

Whoever said 'the devil is in the detail' could have had my job in mind. Patient has INR (International Normalised Ratio-a measure of bleeding time) of 9.0 (9 times normal). Easy - give him intravenous vitamin K. But it falls to me to put in the intravenous cannula. He has tiny, delicate veins and paper-thin skin. Every time I put the needle in, it draws blood, and then, he squeals with pain, moves, and the needle goes right through the vein, leaving a haematoma the size of a golfball. Seven purple golfballs later, the cannula is finally in and I write up the prescription. "Thank you, doctor," he says. Not at all.

This had me in stitches so I had to record it for posterity: "If you fart at school, you have to shout "safety!" and then you have to run and touch the nearest door handle. Otherwise you could get beaten up." - My little brother, on the goings-on at a certain public school for boys

No offence but....

I was on a ward round with *Jo, my registrar, when one of our patients remarked carelessly to her: "your lady colleague there looks like she should still be in school." It's the sort of thing I've come to ignore (or my day would be filled with annoyances). But Jo snapped back immediately: "How rude! She's been through long, hard training to get to where she is today."

It reminded me of some other nasty/ignorant comments I've had:

"I'm really grateful to all you Filipinos - where would the NHS be without you?"
(several erroneous assumptions there...)

"Nurse! I need a bedpan! NUUURSSSSE!"
(usually a gaffe by the same patients who call white male nurses 'doctor')

"Which part of China do you come from?"
(Huddersfield!)

"You look far too young to be a doctor."
(Would you say this to your financial adviser? or your lawyer?)

and of course, anything that begins with
"No offence but...."
(most of these don't bear repeating!)

Day 3 on Rheumatology

Ward 2 appears to be staffed mostly by a bevy of camp male nurses of various nationalities. *Emilio swaggers up to the nurses' station. "Guess what?" he croons. "I'm off to New York and we're staying in a 4-star hotel!" "Who are you going with?" asks *Michaela, a female nurse who is about 6 feet tall and looks like a man. "Oh, Curtis, of course!" Eyelids flutter all round.

Battle Hospital is a strange place. The block across the carpark is literally a pile of rubble. Within Ward 2 there are a few disused bays where not only the paint, but the lights and other fittings are peeling off the walls. I arrived on the hospital shuttle bus, and almost missed the stop. More prominent than the sign with the name of the hospital on is a large placard: "For Sale". In an operation called "Consolidation", the remaining departments are to be moved across town to be become part of the Royal B. Meanwhile the small community of nurses, physios, security guards, doctors, cleaners etc. that remains struggles to offer modern medicine within what can only be described as little more than a ruin. This is not to say Battle is a nasty place to work - I rather enjoy the fact that it is a small hospital and that you are a person here rather than a bleep number.

Dr. K, my new consultant, is a bit of a character (I guess they all are). We're looking at a chest x-ray, and he goes: "hmm... the lungs look fairly clear.. well, there might be a bit of shadowing in the bases, but then, she's Big and Fat." He says this with complete nonchalance. Later, he muses "all these old, crumbly patients, they sit there going nhgh nhgrgh nhgrg (mimics demented old men chattering)..." then he interrupts himself - "mustn't say that, I'll be next (he looks in his 60s). My old man, he was like that when he died. You know, I used to be quite rude when I was younger..."

..so am back home. There's not a lot to do here, merely to melt in the 35-degree heat. The fact that I've only about 2 people to catch up with reminds me of how unpopular I was at school. The old house looks the same, and the volume of suicidal poetry I composed as a morose 14 year-old remains in the bottom of the drawer - right where I left it more than 10 years ago.
Am feeling very rested though, as mom and dad are spoiling me as usual. The Diesel bag I usually use for work looks pristine now that mom has finished with it (the stains from various patients' body fluids washed away). Clothes return washed and ironed and meals just materialise. I could get too comfortable...

the obligatory cheesy entry

It was a good weekend on call. 2 of my patients died and a

further 2 came close - but it's not about the mortality or the

sickness. I guess it was good because I learned loads, got to put

some knowledge (previously classed in my memory as 'obscure')

into practice, with the end result of several grateful relatives

for a change. The challenge, as they say, is to "heal the sick

and comfort the dying" - and not get the two mixed up! Also, some

things are best not mentioned to cheesed off relatives - such as

the real reason I took 2 hours to come and speak to them.

(Because I am the only doctor covering 6 medical wards!)
****
LJ is a 60 year-old lady with terminal lung cancer. I'd first met

her by chance about a week ago, because she had come in for a

neurolytic block (injection of phenol to destroy the nerve

supplying a painful area-normally an outpatient procedure), and

had been so short of breath afterward that she had to stay in

hospital overnight. As the on-call doctor, I was asked to see

her. The anaesthetist who had performed the block had thought of

the possible complications- pneumothorax (a punctured lung) and

paralysis, but a check x-ray showed no pneumothorax, and her

chest expansion was symmetrical. When I listened to her chest,

she was extremely wheezy, but denied having asthma or ever having

been a smoker. I prescribed some nebulisers. She stuck in my mind

because of something quite silly- the nurses hadn't removed her

red nail polish, so the pulse oximeter readings were completely

useless. I guess I would have taken an arterial blood sample

anyway, but I was frustrated that the ward didn't have any nail

polish remover. It took about 4 attempts to get an arterial

sample. She screamed every time the needle went into her wrist,

and kept moaning for "Eddy", the elderly man I assumed was her

husband. Anyhow, her saturations improved with the nebulisers and

oxygen.

I didn't see her again for more than a week, and presumed she had

gone home. Yesterday I was bleeped to say LJ was on a different

ward, and her heart rate was 170/min (nearly 3 times as fast as

normal) and she was drenched in sweat, with a temperature of 38.

I instructed the nurse to take blood for various tests, and to

give her some paracetamol. When I arrived on the ward, she looked

dreadful, slumped over and dribbling from nose, mouth, hair. The

front of her nightdress was covered in vomit and she had wet the

bed. She shook her head when asked if she had pain in her chest

or tummy. Her pulse was thready, even at the femorals. I went for

the biggest cannula I could find (still feeling trigger-happy

from inserting two greys into a lady who nearly bled to death

from a duodenal ulcer the day before - but that is another

story!) and got the nurse to push in a litre of saline as quickly

as it would run. For all that, her pulse dropped to - 120. Not

good. I was convinced at this point that she might die, so I had

the nurse contact her son. I had her cleaned up and sat up, the

oxygen turned up, another bag of saline run. I prescribed some

antibiotics to cover a possible aspiration pneumonia. She now

seemed a bit more stable, so i left the ward as my bleep had gone

off about 8 times, including a call about a man in renal failure

(as he hadn't passed any urine for 18 hours) on the other side of

the hospital.

Her son, *Joe, arrived about 2 hours later. I got him into the

ward's quiet room, and tried to impress upon him the seriousness

of the situation. Although he seemed to understand the terminal

nature of her underlying illness, he still had rather unrealistic

expectations of the outcome. Eventually, I said "if your mother

were to stop breathing and her heart were to stop, would you want

us to do everything to bring her back to life?" At this he became

tearful. He paused. Nodded. "yes, of course," he sobbed. I paused

for a bit, then left to let him gather his thoughts. It felt

cruel, but I'd rather paint a grim picture and have them be

pleased when the outcome is better than expected. (rather than

the converse!)

Called away again. I returned to see him standing by her side,

shaking her. "Mom!" She wasn't opening her eyes. She had

definitely been conscious in the morning, despite being in

extremis. I peeled her eyelids back and sure enough the pupils

were pinpoint. Her dehydration had probably caused a build-up of

oxycodone. I got the nurse to draw up some naloxone. "What's that

stuff?" Joe asked, suspiciously. I explained as best I could, and

started to inject it (see entry below - "a suicide, maybe"). She

came round with a jolt. Joe was visibly relieved, but his face

soon fell when she looked him in the eye and said, "I want them

to stop." "Stop what, mom?" "All this," she said, holding up her

arms, which were covered in lines and monitoring equipment.

Oops, have to go head to the airport soon! to cut a long story

short, she survived to see another day. Also, it turned out that

Eddy and Joe are not on speaking terms as Eddy is his step-dad.

And I am going on holiday so I will never know the outcome - will

Joe and Eddy come to accept that intensive care, CPR etc are not

in LJ's best interest? And so on. Every on-call is a bit like

starting a dozen books and never finishing them.

"Don't live to 101, I don't advise it..."

Edith* has silky white hair and bright, gray-green eyes. Her voice is low and raspy and posh, and larger than you would expect from such a tiny lady. She is very deaf, and on close questioning, is not entirely lucid. But she puts up an expert front - "..and are you one of the doctors? Did you have to train for many years?" "..I'm a hundred and 2 months. Don't live to 101...." she smiles wryly. She came into hospital as her GP thought she wasn't quite herself and looked pale. Her haemoglobin was 4.9 (normal >11) though there was no history of bleeding. We gave her a blood transfusion and some iron tablets. She looks a bit pinker now, but where do we go from here? How far do you go looking for a cause of anaemia in someone who is 101?

...but I don't feel rested

managed some proper sleep last night for the first time in about a week. I can't remember if I've mentioned this in a blog entry before, the Work Nightmare. It's not a proper nightmare in that it isn't particularly terrifying, and certainly does not make you wake up in a cold sweat. Rather (and cruelly), it doesn't wake you up at all - just lets you lie inert while a bland continuation of the day's events at work plays on. Ward rounds, discharge letters, cannulas, deaths... And you wake up exhausted, as if you havn't had any sleep at all, and then you have to get up and go to work again. I think I need a holiday.

presenting... my new picture blog!

in the interests of keeping work separate from real life, i suppose. a one-off link, add it to your bookmark list!

Liverpool v. Juventus

(alternatively titled 'doctors do have a life outside hospital').
quite surprisingly the first game I have ever watched at the pub. 0-0, by the way, just to emphasise the pointlessness of it all. I have no clue about the offside rule, and at the end of the game my only comments were "well, the last 10 minutes of that was actually quite good" - Ranj was unimpressed, and has taken it upon himself to educate me on the appreciation of the beautiful game. Still, I have to admit that its much better in the pub than in your own living room - nothing like 20 simultaneous commentaries from various corners of the room, and people jeering, shouting and clapping at the screen, jumping up in unison at almost-goals.

me-just testing

suicide concluded

phonecall to the coroner today. Mrs. K died on Friday night. So she got her way; but something tells me she didn't know she would be subject to an autopsy (for a graphic description, see my earlier entry ('nausea'). So much for RIP.

a suicide, maybe

...too lazy to try and make this entry reader-friendly, so here goes:
80 year-old woman took 75 GRAMS of tramadol - thats more than 100 tablets- she had obviously been hoarding them for ages. 'Doctor! she's having a fit!' by the time i got there she was lying still, looked pretty much dead, had a smile on her face. the sats monitor was bleeping - sats of 83 - possibly normal for her as she had advanced emphysema and usually had oxygen at home. airway was fine, nasopharyngeal in situ. got the nurse to turn it up all the same- then did a blood gas - first time i've seen a CO2 retainer- so had to turn it baack down again. They always go on about them in textbooks. left her to attend to other patients. bleeped by the nurse - "the patient's daughters have arrived, they want to speak to a doctor." oh no. her suicide note was signed "by the way, I am in my right mind. Love, M (member (lapsed) of the Euthanasia Society)" I wondered if perhaps her daughters were Euthanasia Society members too. or maybe firece opponents? afterall, they had called the police when she had refused to come to hospital. Her daughter was quite calm and collected. I think now that i didn't paint a bleak enough picture. i mean, being realistic, she will almost certainly be dead by monday. even if she lives she will be severely brain-damaged. Her breathing slowed to 8 resps a minute. tried to get a nurse to give some more naloxone. both nurses tied up with another dying patient. finally, exesperated, i said "julie, if you could just get me the naloxone, i'll draw it up and inject it myself" julie is one of the nicer nurses to she opened the cabinet and gave me an ampoule. the IV drugs book said to inject it slowly. good thing i followed that instruction. the stuff works fast. before i had injected the 2mls or so, her breathing had normalised. i left her. and now it is the weekend.