Saturday, 27 October 2007

The Vein Hunter

I am a vein hunter. A tracker of blood, a tribesman of the tributaries of the heart, a pursuer of the pleasures of deoxygenated blood.

Every day, I'm asked to find small veins in elderly people. They tend to be invisible, barely palpable, and wriggly. Holding them down to get a small needle in is like pinning down Harry Houdini on how he did his tricks, or Gordon Brown on when the next election is.

It sounds like a truism, but the real differences between junior doctors and medical students are actually quite subtle. As a student, I often tried to take blood or insert a cannula. But every time I approached a patient, it was with the knowledge that success would be a bonus rather than the expected result.

Now, even though the task is the same, I take three times as much equipment with me: come what may, I have to come away with the red stuff. Failure is not an option. I don't want my patients to croak before the ward round tomorrow. Neither do I want the indignity of having to ask a nurse to do it for me.

This constant focus on finding veins is disrupting my personal life. Tube journeys are nothing more than a prolonged look at strangers' hands. Same goes for parties and restaurants. Flicking through the tabloids over breakfast, even the more popular parts of page 3 girls get only a cursory glance before I assess their venous access. It's embarrassing.

Maybe it's just an obvious sign of a deeper malaise. I rush around without ever having the time to examine someone properly. Clinical skills teaching with the medical students on my team is about the longest I spend with any one patient. So it's not surprising I'm constantly trying to pick up things with simple observation.

This doesn't mean you won't be a little nervous if you catch someone on the bus staring at your hands. But maybe you shouldn't shove them in your pockets straight away. Try pointing to a vein, and smiling encouragingly. It'll make your junior doctor's day.

Wednesday, 10 October 2007

The Clinical Incident

Throughout the ages, small pieces of paper have changed the lives of millions of people. Voting slips. Eviction notices. Parking fines.

But these pale in comparison to the sheet of paper that rules the NHS with an iron fist. It's the Mao Tse Tung of the written word. The Joseph Stalin of A4. It's known as "The Clinical Incident Form".

It's supposed to be a routine thing, a little message to the hospital managers when something's gone wrong. It's supposed to help minimise the chances of the same mistake being made twice.

Like any well-intentioned bureaucratic device allowed out into the real world, it's grown into something very different. Nurses now brandish The Clinical Incident Form as a weapon. Forgot to write up fluids? They could end your career with a well-filled out page 1. Did you wash your hands just out of sight of the "Handwashing Audit" team, losing the ward valuable "points? You better get ready to be Formed.

Even though the worst that can happen is a mild-mannered email from Risk Management, getting the Form feels something like getting a sexually-transmitted infection. You don't want either of them, and they both tend to come from a nurse you'd rather not wake up with more than once.

The pen-pushing culture is running riot at the moment. Must be something to do with waking up in the dark and having to wear a proper winter coat in the mornings. We were brutally wrenched from the wards earlier this week, dedicating an entire morning to talking about "diversity in the NHS". This was considered more important - and thus worthy of more teaching time - than something rare and of little clinical use, like how to deal with a heart attack.

Once again, I fear that our superiors haven't quite got the hang of how to say NO to the Department of Health and its bizarre priorities. Surely that should be a Clinical Incident?

Monday, 8 October 2007

For bleep afficionados


The (under)Graduate

My partnership with the Mountain Goat has been put on hiatus: I've joined a different firm. I now accompany The Big Cheese for his ward rounds. In management circles, this is known as "being headhunted". Or "constructive dismissal".

The Big Cheese runs a tight ship, which means that the ward round's conducted at the speed of light. There's barely enough time to collect the registrar and the students before it starts, let alone find the nurse taking care of each patient.

The one-minute-medicine approach works well for the consultant, who's then free to play golf and eat small junior doctors for the rest of the day. Consultant Surgeons see everything in black and white: you're either ready for surgery or ready to go home. Convalescence is for wimps. This speeds up the discharge process.

It's less efficient from my perspective: I spend the rest of my day answering phone calls from nurses. They get concerned when their patients disappear home, especially if it happens during their bre
aks, which take up approximately 65% of their working day. I've seen a nurse arrive at work, take off her coat, and be told by her supervisor that it's time for her break.

When a nurse is "on her break" she is not to be disturbed. I've never seen it myself - I'm not allowed in the staff room, which is for reg
istered nurses only - but I'm told that they put themselves into a Zen-like state, into which no earthly problem can intrude. I imagine they write haikus, play the mandolin, and discuss the philosophical issues of the day, before dusting themselves down and doing the drug round.

To add to the general chaos, the Big Cheese has taken on an assortment of new medical students. They're so fresh to the wards that one of them - with no sense of irony whatsoever - declared "I love patients".

Even the nurse on her break cracked a smile at that one.

Sunday, 30 September 2007

Name and Shame

Introducing myself never used to be difficult. I had a name, I used it, the conversation moved on.

Pretending to be a responsible professional makes things much more difficult. I don't know whether to introduce as Dr {Worm}, or rely on a more user-friendly first name.

The end result: total tongue-tying. A mumbled conglomerate of first name and surname. This leaves the indelible impression that, far from knowing the ins-and-outs of acute medicine, I'm not even sure who I am.

Not the look I've been striving for.

The trouble is, every patient seems to need a different doctor. Some patients prefer the white coat and distant manner, whilst others - usually the ones with Facebook accounts - would rather have a chat with their medical team. Not for them the formulaic introductions and formality of a bygone age.

The UK's pioneering a "Choose-and-Book" system, allowing patients to choose their hospital specialist. GPs are supposed to be able to point their patients towards the specialist who will "suit" them.

But family doctors have a responsibility to send their patients to the most competent specialist, not one who introduces him/herself by their first name. When I'm sick, I don't care if my surgeon's manners are a little old-fashioned. He can demand that I wear a top hat and tails, as long as his surgical technique's up-to-date and he gets the job done better than anyone else.

The new style of medical training is pushing through doctors with impeccable manners, first-name introductions and delightful bedside etiquette. As a nation, we haven't decided whether that's acceptable compensation for a lack of technical expertise.

We need to make up our minds before the decision's made for us. I respectfully suggest that maybe a little professional formality isn't so out of touch after all.

Monday, 24 September 2007

The Royal We

I've started talking in the plural.

"We've decided to do this test", I hear myself explaining loudly. "We should try this drug". "We need to get you to pass wind".

I'm not entirely sure how this started. Nor am I clear who's included in this fictional group, or why I need their support.

My subconscious seems to have assessed my medical knowledge, and found it inadequate. Subconscious Worm decided that no sensible medical governing body would licence me to take potentially life-changing decisions on my own.

Ipso facto, X-factor, all my decisions need to be group ones. Safety in consensus.

The Royal We is comforting, for me and the patient. It says there's accumulated wisdom behind my seemingly random choices, method in my madness. Multiple physicians agree with my diagnoses; they're just busy doing other things at the moment, so you can't see them.

Sometimes I wish there was more of a real group dynamic with my patients. Having to talk to people - or still worse, get near them - on my own can be truly horrifying. Tom, an A&E regular, was not a pleasant one-on-one interaction. He smelled so bad, I actually retched as I tried to take his blood. When he finally told me, "f**k off, I need to sleep off my hangover", it was a relief.

At other times, having someone else there makes a bad situation worse.

On call, I was asked to insert a catheter for a guy who couldn't pass urine.When I put in some local anaesthetic so that the catheter wouldn't be painful, his nether regions responded to the cold gel, like a toddler in a swimming pool. Instant wee, all over my (gloved) hands. Having his wife there, as well as another doctor, wasn't quite the mental group hug I was looking for.

Ultimately, you stand alone with your medical decisions. No-one else can take responsibility for the prescriptions I write, the tests I order or what I tell my patients. But I'm getting more comfortable with that - maybe I won't need the Royal We much longer.

I'm even getting ready to hold my hands up in the air and admit it when I make mistakes. Let me just clean the wee off them first.

Saturday, 22 September 2007

Mad angry

Rich, a male Filipino nurse, is clearly insane. Despite plenty of evidence to the contrary, he's chosen me, basically a medical student with a staff discount in the canteen, as his personal icon of clinical excellence. A ward-based Dr Quinn Medicine Woman or Karl Kennedy.

He's also got a touching faith in our drugs' ability to cure any medical complaint. Sometimes his enthusiasm for the chemical cosh oversteps the mark. Take Mr Harris, a middle-aged firebrand who was getting frustrated that he didn't feel any better despite the improvements in his blood tests. When Mr Harris got cross with one of the nurses serving him lunch, Rich asked me to prescribe an anti-psychotic.

With a hopeful look in his eyes, Rich handed me a syringe he'd already prepared, with the immortal words: "Haloperidol, doctor?"

I looked at Mr Harris, by this point fiercely attacking his mashed potatoes, and decided that a powerful sedative may not be necessary.

Making sense of emotions like anger and fear - mundane events in the real world - is actually quite difficult in hospital. Arguments can come from personality clashes, but can also be the first sign of an acute delirium. It's the same with new symptoms: aches and pains that most people don't bother to mention to the GP take on a new, possibly frightening significance when they're already in hospital for something else.

I left Mr Harris to enjoy the rest of his lunch in peace. Even if he did have something serious going on, it certainly wasn't spoiling his appetite. It wasn't a trouble-free decision though: I think I may not be Rich's number 1 medic any more. He asked another junior doctor to prescribe the teatime sedatives.