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.

Tuesday, 18 September 2007

Chris Ak-abuse-i

Many people frown on racism. Not the Worm's team. For at least one of our patients, racism is actually a very positive sign. As far as Mr Bradshaw is concerned, the more racist the better.

Other patients have their blood pressure and pulse monitored every 4 hours. Mr Bradshaw gets asked how he feels about immigration.

He was a devoted racist before he came into hospital. Since he was admitted, any weakening of his belief system has correlated pretty well with him getting sicker. Racist abuse is the best barometer we way have for him: any sign of a "live and let live" attitude is pretty worrying. We want to get him back to his pre-hospital best, which means aiming for some truly objectionable opinions.

It's usually the other way round - as patients get more confused, they get more abusive. Abuse of medical staff can itself be a worrying symptom. I for one was extremely worried when a small elderly woman in the canteen today threatened me with a plate of carrots and tried to eject me from the area. Most worryingly of all, bystanders were more concerned by the threat of carrot spillage than any potential bodily harm on my part.

A lot of routine abuse is aimed at the nursing staff, who bear the brunt of patients' frustration. Relatives also head their way: 2 nursing students burst into tears earlier, after being screamed at by an angry son. It was interesting to see him apologise afterwards to other patients, who he thought he might have disturbed with his outburst, but not to the two girls he'd reduced to tears.

I found some respite from this evening storm at the nurses' station by slinking off to do some small jobs. When you're covering other people's patients it's easy to see them as one-off jobs: bloods, cannula, Xray. Tonight was different - it was an absolute pleasure to have a proper conversation at normal volume with someone who wasn't racist or confused, or both. I actually paid attention to the patient I was sticking needles into, and it paid off. He was a professor of politics who talked me through the break-up of the USSR, because we both felt like being real people for a few minutes.

The doctor-patient partnership is like any other abusive relationship. There's an infectious sense of optimism when things go well. When things take a turn for the worse, both partners promise to try harder, and to watch out for the warning signs of impending conflict. I for one know to look out for the racism and the carrots.

Friday, 14 September 2007

Fatality mentality

Mr Sumner is not a well man. 97 years old and just 4 days after major surgery, he initially stunned us with the speed of his recovery. Then, ten minutes after lunch, he suddenly slumped back into bed, cold and unresponsive.

I broke into a cold sweat of my own - none of my patients have died yet, and this was too close for comfort. I actually felt nauseous. Somehow the rising tide of bile stayed down just long enough for me to do the basic blood tests and call for help.

Even when you haven't made a glaring error - as far as you can know - the pressure when patients become acutely unwell is immense. It really does feel like your entire career, not to mention your mental stability, is riding on every change in the patient's blood pressure, every cough or hiccup.

Maybe this sensation (or something like it) stays with you, regardless of how senior you become. But I doubt it. Noone would stay in the job. So when do you lose it? Does the terror of catastrophe recede after the first patient death? Since I haven't yet had to certify any deaths, I can't stop thinking the first one must be just around the corner. At any moment, my patients could start dying all over the place. And I really don't know how I'll cope with that.

Excuse the abrupt end to the post, but I need to get some fresh air. I feel a bit sick.

Tuesday, 11 September 2007

Vote for Pedro

Our new patient Napoleon is hard to read. More Napoleon Bonaparte than Napoleon Dynamite. Asking him for intimate personal information - like, for example, whether he feels thirsty - is more taxing than you'd think. He gives out these details piecemeal, like a serial killer toying with the police. Finding out when his bowels last opened takes the entire day, and usually ends up with me negotiating with the nurses to get him a double helping of dessert. He's a master, and gives away nothing for free.

He's pretty clear on one thing though: he's smarter than I am. He peppers our conversations with references to the times he's Googled his condition, and the self-help groups he's been to.

As far as he's concerned, a medical degree doesn't count for much if you don't actually have the disease. We've disagreed on so many aspects of his treatment that I've honestly considered telling him that I too have a complex intestinal disorder, just so he'll hear me out.

I can't fault him: his rules apply to everyone. Consultants get the same disdain as entry-level graduates. Studies in major journals are rejected: the authors don't have the symptoms, so they don't know what they're talking about. Napoleon's logic is impeccable.

This Frenchman's a tough nut to crack. Short of acquiring his disease, which may or may not necessitate a bizarre infectious agent, I'm not going to win this argument. I'm not even on a level playing field. This could well be my Waterloo.

Saturday, 8 September 2007

Someone ate my chocolates

Contrary to what you've heard in the papers, there are loads of jobs for doctors. LOADS. I was lucky enough to see the job allocation process in the flesh. In the canteen.

Big boss consultant: "So, you're working here next month?"
Junior doctor: "No, I'm a locum"
Big boss: "No-one passed on the message that we wanted you to apply for the permanent post? You were a shoe-in."
Junior: {silence}
Big boss: "So do you have any friends that might be interested in the job?"
Junior: {dark clouds of despair make response inaudible}

This kind of thing isn't good for morale. I almost lost my appetite at the sight of a doctor's career being derailed next to the coffee shop. I had to keep eating, though, because the junior doctor's body needs near-constant energy intake. The perpetual stress of not being very good at your job burns up calories surprisingly fast. So when a patient brings in a box of Quality Street to say thank you, it's not a meaningless gesture. It's literally a lifesaver.

The Big boss making job offers in the cafeteria thinks otherwise - he says we need gratitude in writing, to the chief executive, thanking the hospital for the good care the team's provided. This "balances out the complaints". Is there a complex equation, or does one thank-you letter cancel out one complaint? We must be told.

I admit it's nice reading the letters on the ward noticeboard. You don't often get a pat on the back for doing your job, just a sharp telling off when you forget something. But it does make you realise how patients value totally different things to doctors.

No-one's written "Thank you for the inventive antibiotic regimen that saved my life despite my multiple allergies." That's the kind of thing that would make my colleagues glow with pride. What people actually write ("Thank you for your kindness") actually reflects more on the nursing care, and makes doctors feel small because it's something that requires 0 years of medical training.

So, whilst I wait for the first compliment on a job well done, I'm going to the canteen. For a coffee and a job interview.

Tuesday, 4 September 2007

Living for the weekend

Covering the wards over the weekend is like travelling to a family wedding in Norfolk. People seem familiar, but they all turn out to be far more bizarre than you'd ever imagined. And the food is disappointing.

You meet a lot of patients whose charming eccentricities as smiling faces in the hallway suddenly become downright freaky. Take Alan. A normal pudgy teenager during the week, somewhat reluctant to get out of bed, turned into a growling Rottweiler.

He wouldn't stop asking whether the operation had ruined his chances of becoming a professional bodybuilder. Given that he refused to stretch his legs even when warned he was heading for a DVT, I thought it unlikely he'd be a regular enough visitor to the gym to get himself a prize-winning six pack.

I quite like the idea of going to his post-op Gun Show though.

Mr Jackson was quite the opposite - a real wanderer. He roamed the corridors with zeal, telling anyone who would listen that his doctors were doing nothing for his diarrhoea. In our defence, it was difficult to do anything for him. Every time we came to see him, he'd locked himself in the toilets, smoking.

Unusually for someone with diarrhoea, he had difficulty providing a good stool sample. I explained that it had to be as sterile a sample as possible, so his suggestion of scraping it from the inside of his pyjamas - whilst inventive and showing an admirable ability to think outside the box - wouldn't actually work.

Nor would the lab accept the sample on the toilet paper that he waved in front of my face.

These people seemed so normal during the week. It almost makes me worry about seeing the other doctors socially - if patients can be this different outside of office hours, what on earth are my workmates hiding? The mind boggles.

Next weekend, I'm staying in.

The Meaning of Pain

I have awarded Jenny a Pain ASBO. She is no longer permitted to complain about pain within a 1-mile radius of the hospital.

Before the PASBO, Jenny claimed it was agony each time I took her blood - despite my getting it first time, with a tiny needle, no digging around, in and out in 30 seconds. She found the experience excruciating, despite receiving the "Magic Cream".

The "Magic Cream" is a local anaesthetic that you can rub into the skin, deadening the nerve endings. It's used mainly in paediatrics, mostly because children like the idea of magic.

We all smiled when Jenny requested the cream - especially when she earnestly referred to it as "The Magic Cream". Jenny's a 60 year old lady, and you could hear the capitalised letters in her voice. We stopped smiling when we realised she was serious, and wasn't prepared to have any blood tests without it.

It's easy to envisage a world where hers would be a perfectly normal request. As people emphasise the importance of customer service in medicine, and patients become 'clients', the idea of leaving a customer in any pain at all sounds increasingly ridiculous. The hospital's Pain Team - a nurse-led conglomerate of specialised nurses and anaesthetists - even talks about the human right to be free from pain.

But pain, just like blood pressure and temperature, is a really useful indicator of how things are going. When the pain of the next blood test is the worst thing on the horizon - not the pain of the disease that brought you into hospital - things are actually looking up: you're probably getting better. So, whilst you're cringing at the thought of that needle, the doctor's cringing at the thought of the discharge paperwork.

I don't think being in hospital can ever be a totally comfortable experience.
If you really wanted a relaxing couple of days with a good-looking man in a white uniform, you'd book yourself into a spa, not somewhere that looks like Wormwood Scrubs. Still, it needn't be agony. A quick chat with the medical team about how reassuring it is to fear the odd blood test should make things less painful all round.

Wednesday, 29 August 2007

Hazing the new guy

No-one's spanked my buttocks. I haven't been forced to eat anything more unsavoury than the usual canteen fare, and my eyebrows remain unshaved.

As far as initiation rituals go, this institution has been surprisingly gentle with me.

But there's no doubt I'm still the
new boy. Some of the nurses, with more years on the wards than I've had in medical school, like to pull rank. Sometimes with good reason.

I often ask their advice. Most nurses are happy to give it, and most of the time I agree with them. They've helped me survive my first month as a doctor, and I'm unbelievably grateful to them.

There are exceptions. The Lemon is very similar to the Potato, except that her skin is more sallow, and (ironically) she has a larger chip on her shoulder.

She's already had run-ins with the Giant, who's been unfailingly polite to her. It was my turn today.

Jim was the reason for her fury. He'd been hiding his tablets. To be more precise, alternately hiding them behind his pillow and throwing them away. He didn't like the chalky taste.

I re-assessed whether he needed them, and decided not to re-prescribe them. This did not go down well. Over the phone, in a furious screeching voice, with bile dripping through the telephone wires, the Lemon demanded to know what I thought I was doing. My explanation clearly didn't cut the mustard, because she hung up on me.

One thing they definitely don't teach you at medical school is industrial relations. It's all experience. The Giant can shrug off a thousand minor arguments each day, on the basis that a) it's his job, and b) there's less oxygen up there next to his head, so he needs to save his breath for the important stuff.

The Mountain Goat has a different technique for avoiding the day-to-day hassle of the job. He's a Consultant, so you have to attain quite a high rank before you can take him on. By that point, most people have tired of the petty disagreements, and would rather just treat patients or go home and see their families. Also, by the time you've composed your thoughts enough to start an argument with him, he's halfway up the stairs.

I don't have the experience, or the status, or the stairwell speed, to get round the Lemon. But I do have some sympathy for her. Hospital admissions have increased massively in the last decade, and nurses have borne the brunt of that. They've got too many patients, and I've still got too few.

The old rules of the doctors-and-nurses game are changing. The boundaries are blurring: each year, women dominate medical school intakes, reversing the previous gender imbalance. At the same time, nurses are taking on roles once reserved for doctors - prescribing, management of chronic conditions, specialisation. It's an odd relationship, an experienced nurse and a brand new doctor.

So I'm hoping that we'll sort things out, the Lemon and me. And then my experience of the nursing profession won't be all sour grapes.

Monday, 27 August 2007

Sizing you up

I like walking round the hospital with the Giant. He's so tall, it's like having your own bodyguard. Almost a one-man entourage. When I gave up rapping to concentrate on the medicine, I thought I'd left my "bling" lifestyle behind, so this is quite a treat.

Not everyone takes so well to his enormous height. A small Filipino nurse started screaming at him to "BACK AWAY, BACK AWAY NOW", startling everyone in the vicinity. Turned out she just had a bad neck and staring up at his face from a close distance was giving her serious pain.

In hospital, I think everyone's judged on their physical appearance. Patients judge doctors, doctors judge doctors, and doctors definitely judge patients. "You look better"; "this guy looks dehydrated", "that doctor's nervous". It's part of the clinical assessment.

Sizing someone up isn't always so straightforward. Take obese people. Aside from the negative social stereotype, it's more difficult to treat a patient who's overweight. It's harder to take blood, harder to get their wounds to heal, and much harder to interpret test results. We had a patient who had to be referred to a different hospital just because he was too big for our scanner. He literally couldn't have a CT scan because he'd break the machine. There was talk of sending him to the Imaging department at London Zoo: a serious suggestion, because it's been successful before.

It goes both ways: there's evidence that patients trust obese physicians less than thin ones. So while I'm wondering why you didn't stop eating Big Macs after your second heart attack, you might be wishing you had a junior doctor without a pot belly.

Maybe this isn't any different to a normal social encounter. People respond to the way you look and dress, and you expect that. But when it comes to health, size really does matter, and doctors need to be able to take a dispassionate look at an expanding waistline without the interference of a social stigma. I just hope that there's enough appetite there to take on the obesity epidemic.

Saturday, 25 August 2007

At the Coal Face

I see more of our patients than either the Giant or the Mountain Goat. This has some benefits, but also some drawbacks.

Take Gerry, for example. He is an enormous young black man, who had part of his bowel removed. Like many of the patients (and staff), he finds the heat of the ward unpleasant. Unlike the rest of us, however, he doesn't consider himself restricted by social convention, and so spends most of the day dressed ONLY in a small pair of underpants made of string-vest material. Like a little hammock for his privates.

I don't think the Giant or the Mountain Goat are aware of this, because Gerry always manages to "dress up" (i.e. put his gown on) for the morning ward rounds. In my mind, it's the equivalent of any other patient wearing a tuxedo: it adds a sense of occasion and formality to an otherwise mundane scan of his vital observations. I then spend the rest of the day desperately trying not to scan his vitals.

The patients also see more of me. Not in the Gerry way, of course. But they see me getting frustrated when people don't answer my phone calls, when small requests that I made hours ago still haven't been done, when I'm asked to physically carry messages to the furthest ends of the hospital that could so easily have been emailed in the blink of an eye. The rest of the team, hidden away for most of the day in theatre, keep their air of mystery. I, on the other hand, can only muster the physical gravitas and dignity of a man dressed in a small white banana hammock.

I like to think my relationship with the patients is less superficial than theirs. I don't struggle to remember the patients' names, and haven't yet started referring to them by their bed number or operation. That may be because - in my entire professional career - I've had fewer than 15 patients. Medical memory loss (forgetting patient's names whilst remembering intricate details of their medical care and previous surgery) hasn't had a chance to develop yet.

There's a certain protection in being far away from your patients, in clinic or in theatre. I don't have that luxury yet. I'm accosted by everyone on the ward, patients, relatives and staff, whether I'm responsible for them or not. I've lost count of the number of times I've tried to calm down the elderly man with dementia who doesn't understand where he is, let alone that he's only on our ward because they've run out of beds on the floor where his actual doctors work. For a man who's forgotten that his wife died 5 years ago, the concept of "outliers" isn't really relevant.

There are also physical risks. One of my friends felt a niggling pain in her foot, only to realise that she'd stepped on a used needle that some idiot had left on the floor. The ward's a dangerous place when you're just beginning your career. You don't know where anything is, who anyone is, or what you're doing. People seem unsympathetic, and you're constantly trying to hide the fact that you're massively out of your depth.

I'm starting to enjoy myself :)

Tuesday, 21 August 2007

I don't need a doctor, I'm having my lunch.

The Potato, a ward Sister who looks exactly like a potato would if it were human, wanted me off the ward.

It was "Patients' Protected Mealtime". This tries to discourage staff and students from unnecessarily bothering patients who are trying to eat.

The fact that I was at a desk, quietly reading through a patient's notes, well away from any other human being, apparently didn't make any difference. Just my presence was upsetting the natural balance of Primrose ward.

Without me there, of course, patients would feel right at home. Dignity would be instantly restored, wounds would close up, and - in the case of one unfortunate lady in bay 1 - bowels would stop opening all over the floor. Doctors are the cause of all of these ills.

I'm not against the idea of giving the patients back some level of control over their lives. They're carted off to their scans, or their operations, without much warning. They're stripped down, then poked and prodded by unkind fingers. This is often worse than whatever disease they came in with. Lots of people put up with occasional nausea and vomiting at home, but how many would let complete strangers come into their bedroom, ask them if they've opened their bowels, then put a finger in their bottom to check?

But I actually find the Protected Mealtime a massive cop-out.
Why bother with humane nursing or simple courtesy, when patients have a set time each day to feel like themselves again? Rather than addressing bad medical care that makes people feel less than human, we've created a gimmick that glorifies the pallid slop we make patients eat.

It's a
weak, flimsy idea at best, badly misunderstood, poorly implemented and almost useless in practice.

You might as well call it "Dignity Hour".

Which is why I laughed when Potato suggested I move on, and got on with my job instead.

Monday, 20 August 2007

A Tale of Two Ninnies

A lot of people hate hospitals. I never counted myself one of them, although that could change. Two patients today were quite the opposite: desperate not to go home.

Reg is a nice guy. His neighbours come to visit him in hospital, he's polite and he doesn't give the nurses any trouble.
He holds court at the centre of Male Bay 2, advising the younger men on life and love, and gently harassing the prettier doctors.

He has diabetes, which his specialists have struggled to control with tablets and insulin injections.

They've struggled because - whatever they prescribe - Reg doesn't take it. He says he does, but he doesn't.

It's not like Reg is unaware of the consequences. He's lost most of the feeling in his legs because of the diabetes.

But whenever he goes to his diabetes clinic, an air of collective madness descends. He says he takes his drugs, and the doctors believe him. And then they prescribe bigger doses. Perhaps they take some happy pills at the same time.

This is all well and good. But when Reg came into hospital, the nurses gave him the doses of insulin he was supposedly taking every day. And his blood sugar dropped dangerously low, because his body had never seen that much insulin before.

These attacks of low blood sugar can cause permanent brain damage if untreated. Reg would rather risk that than be honest with us.

I find this side of Reg extremely odd. But he's got so used to lying to his doctors that I'm certainly not going to be the one to change him. He seems to take great satisfaction from "outfoxing" the medical profession. Even if it kills him, he's sticking to his story.

Charlotte is a young woman with a religious husband and a small child. Despite her appendix operation having gone well over the weekend, she didn't want to leave. She begged the consultant, "Can't I just have one more scan?". She pleaded with the nurses. She tried to enlist the other patients' support.

And, when everyone else left, she asked me not to send her home.

I couldn't understand what the hell she was on about. She was clearly feeling better, walking around the ward, eating and drinking. I felt myself struggling to keep my frustration in check. I had a thousand things to do, and spending more time with her wasn't going to earn me any brownie points with the Mountain Goat or the Giant.

It took several exasperating conversations throughout the day before I even had an inkling what the problem was.

She was worried how she'd cope with having to look after her baby, feeling drowsy and under the weather. With no help from the husband or his parents, she couldn't leave the hospital until she was 100% better.

A desperate, annoying young woman with a legitimate grievance. No-one tells you how to deal with this.

I can write a prescription for paracetamol (if you give me about 20 minutes), but there's no section in the BNF on prescribing for family inadequacies.

I did what I could. I offered to talk to her husband about the support she'd need after such a major operation. I also took time going over with her - at great length - the two drugs she'd need to take home, because, in addition to her emotional issues, Charlotte was a bit slow.

They eventually left for home, Charlotte and her husband, without looking back. I hope they don't complain that she felt forced out of hospital before she was ready.

Patients like Charlotte and Reg leave a sour taste in my mouth. It's easy to dismiss them as malingerers, medical time-wasters. It's so tempting to dream of the other patients I could have helped instead of the fruitless discussions about drugs that Reg pretended to take, or why Charlotte felt tummy pain when she poked her stitches.

But the reality is that I couldn't help them. I didn't even scratch the surface of what made them tick. Even if they'd been my only patients, I'd have been at a complete loss. That's the real frustration. So I wish them well.

Friday, 17 August 2007

Like a leaping mountain goat

We're quite worried about one of our patients. Simon had an appendicectomy, but because his appendix burst before the operation and released a lot of pus, his bowel hasn't been working since. His abdomen has swollen, and he's in a lot of pain.

I'm not the one to decide whether we should keep going with Simon's conservative treatment or take him back into theatre for another operation. I went off to find a senior surgeon to review him.

My Consultant, The Mountain Goat, is a short stocky man who leaps up stairs three at a time. He does not tell us where he is going, and he does not look back to check that we haven't lost him. We follow him through the hospital like inept henchmen in a James Bond film.

When we finally catch up with him, the look on his face is clear. To him, we are odious slow toads who are mentally and physically weak. We will never make it to consultants.

My registrar is a Giant. He is a tall man with an easy smile. The Giant was on call today. He made several life-or-death decisions each hour. He is an impressive doctor with a fine CV, charming with the patients, and cool under pressure.

We realised today that he passes wind often. He will happily deny it if there is a consultant around. When the consultant leaves, the Giant admits he has a problem.

We were in the operating theatre when it happened. Like Simon, the patient's bowel had become obstructed, and needed an operation to relieve it. The initial moments were uneventful, but when the Giant released his flatus, the smell was so bad that the other surgeon honestly assumed part of the patient's bowel had died.

As the most junior doctor on the team, I am now blamed for the unsanitary colonic discharges of my colleagues, as well as for administrative and medical mistakes.
This is the side of medicine that people don't see. It's why I laughed when a casual acquaintance said that "medicine must be a glamorous career".

None of the junior doctors in my hospital leave on time. We stay late to make sure patients receive the overnight care that they need, and then get discharged when they are ready to go home.

When we are spotted, still at work, we are accused of loitering in order to charge the hospital overtime. Within the next few weeks, we will be asked to sign a form agreeing that our jobs do not require the hours we're currently contracted to.

I quite wanted Simon not to die over the weekend, so I stayed on to make sure he had extra blood tests and that the on-call team knew all about him. I don't feel bad about that, even if it does end up causing a stink with Human Resources.

Tuesday, 14 August 2007

The UK's Foot In Mouth Epidemic

Small talk is pretty difficult in medicine. It's not like doctors and patients get together to discuss the day's events over a pint. The situation's pretty simple: one of you has information to give, or something unpleasant to do, and the other one wants you to get on with it. Any conversational interlude just delays the inevitable.

But is silence really an alternative to awkward chitchat?

I went to a pre-assessment clinic today. This is where, 8 weeks before their surgery, patients are told whether or not they are fit enough for the operation. The clinic is run by a Nurse Practitioner, who runs through a checklist of questions written by doctors and does some blood tests. Some of these blood tests have a "sell-by date" on them - usually less than 6 weeks. So, when the patient comes to hospital, I have to repeat them anyway. This sort of thing is the reason why your doctors look overworked, and why your wards smell of mould.

This clinic was for morbidly obese people seeking weight-loss surgery. When you weigh more than 150kg, and you need special equipment just to get onto the operating table, surgery can be risky. I needed to take an arterial blood sample, which is trickier (and more painful) than a normal blood test.

Cue the small talk.

This time, I had an ally: Sarah, another junior doctor, trained in communication skills, who would distract Irene, the Morbidly Obese Patient. What I hadn't counted on was her desperate opening conversational gambit:

"What's your favourite food?"

I frantically tried to signal that another topic might be more appropriate, and we moved onto safer ground: Irene's son.

And then, inexplicably, his favourite food.

Sarah probed and explored the culinary preferences of everyone Irene knew. I wanted to lessen our little trio's communal pain, preferably by taking the needle out of Irene's arm and sticking it into my eye.

Irene had already been through a battery of medical tests by this point, as well as psychological screening to make sure she didn't have an eating disorder like bulimia.

I'm no expert in bariatric surgery, but I would imagine that having a junior doctor talk about what you like to cook for your family in the evenings is not what you need to hear.

But finding the right words on the wards isn't easy at all. I just can't give patients what they want. When "You're going home today" is the only phrase that counts, it doesn't really matter if I've inadvertently trodden on some cultural toes, brought up bad memories, or stumbled into a family argument.

As soon as patients realise we won't be going for a pint any time soon, they stop listening to me anyway.

Monday, 13 August 2007

Bottom of the Food Chain

I don't actually practise much medicine. I'm more like a PA to the general public; organising their appointments, making sure they're in the right place and getting the right scans at the right time. I don't make cups of tea, but neither am I called upon to make fine medical judgments. I write notes dictated by other doctors, and watch enviously as nurses and physiotherapists make decisions of their own.

Even the patients are more in control of their own destinies. Ms D, a young lady with a recurrence of gallstones (despite having had her gallbladder removed with keyhole surgery several years ago) was discharged today - but only because she was determined not to miss her holiday flight, booked for tomorrow morning. We would have kept her in for another couple of days, but she took charge.

In the pecking order of the hospital, I am senior only to the nurse who keeps believing the dementia patient who promises not to pull out his feeding tube.

I'd like to think it's not any particular personal deficit that's relegated me to this algae-like status. Most of the other new doctors inhabit the same desolate plain of existence.

As instructed by our seniors, we congregate outside the Imaging department, bearing requests for expensive scans. The Radiology registrar on call listens contemptuously, and then dispenses his verdicts like Simon Cowell on acid. If you thought auditioning for X Factor was tough, try getting a same-day CT scan in your local hospital. G4 would crap their pants.

Due to some inventive changes to the rota by the Human Resources department (ensuring that noone in Brussels is upset by the number of hours I work in a week), I now have very few patients to look after. This may seem like an odd complaint, given that last week I was almost catatonically stressed by my workload. But hanging around a hospital turns out not be much fun when you're neither a patient nor gainfully employed there. It's also annoying that, of the 5 patients we do have to take care of, we're largely watching them get better by themselves.

At least in medical terms, I know exactly where I stand. There's surprisingly little ambiguity on the bottom rung of the ladder. Truly, I am the lowliest worm.

The only way is up??

Friday, 10 August 2007

Ups and downs - Me and Them

My mood is veering wildly between momentary highs and swooping lows. The brief pleasure I take in having explained something to a patient's satisfaction, so that they finally understand what their doctors are doing to them, is rapidly overtaken by my despair that I STILL CAN'T GET A CANNULA IN THEIR SMALL WRIGGLING ELDERLY VEINS. It sends me home literally hanging my head in shame. And because I'm working nights, it's the last thing I think about before I slump into bed.

I am the ultimate hands-off healer, a soother of furrowed brows, a talker. Woe betide anyone who needs an intravenous medication. I am not your man.

Mr Clark was a lovely old gentleman. With a soft Scottish accent, he was the politest, most grateful patient I've seen on the wards. His medical problem - inflammation of the gallbladder, very common and easily treated - was quickly brought under control, and he was sent home with instructions to recuperate for a few weeks. He would then come back to hospital for a routine operation to remove his gallbladder by keyhole surgery. Lovely stuff.

Things didn't work out quite like that.

When he was discharged, he went straight to the pub. Presumably to feed his raging alcohol addiction, which he hadn't mentioned - and noone had asked about. Nice polite old guys, who don't smell and have good personal hygiene, aren't alcoholics. Everyone knows that. Don't they? He didn't.

He was brought back into hospital the next day, having been arrested for shouting abuse at his neighbours and waving a knife in their direction. Despite his best efforts after discharge, 4 days of enforced abstinence in hospital had sent him into acute alcohol withdrawal.

We managed to calm him down by treating the alcohol withdrawal, but his gallbladder problem has flared up again. Back to square one.

So I'm not the only one going through hell over the last few days. And from now on, every patient I meet is presumed alcohol- and drug-dependent until proven otherwise.

Wednesday, 8 August 2007

Little Black Box

I hate my pager.

Only a few days into my job, and this little black box of doom controls my life. It stops me buying the sandwich that I've rushed down 5 flights of stairs for. It stops me talking to patients, because if I quieten it for a moment to finish my sentence the impatient person at the other end just pages me again. And it seems to know when I'm on my way to the toilet.

As an implement of mental torture, nothing else comes close. At least your time was your own on the rack.

And you can't screen out the inane calls, because the only message you get is an unidentified number. Some of the calls are surprisingly revealing about the person at the other end - i.e. they're obviously blind, illiterate or just lazy.

I'm tempted to turn the damn thing off, at least when I need the toilet. But I have a feeling the pager is stronger than I am. And it probably has more friends in the hospital than I do - it's like any other office nemesis, except that it has about 3000 identical twins on its side who work in the same building.

So, for the moment at least, I'm putting any hope of normal bladder function to one side, and heading for a phone.

Tuesday, 7 August 2007

Frankie says relax

Patients with foreign objects stuck in their bottoms - universally - have a great cover story. It's never an awkward admission that something went wrong. Never a wry smile, never an acceptance that certain events led inexorably to their wholly-foreseeable conclusion.

Instead? "I fell on it, Doctor".

In order to believe this, I would have to believe that:

- a surprisingly large number of people are INCREDIBLY unlucky


- a lot of people who would quite like the experience of having something up their bottoms do a lot of DIY, at considerable heights, and then fall with something approaching good fortune directly onto the object of their desire.

During some work experience abroad, for example, I met a patient who had been admitted to hospital after changing a lightbulb in his kitchen. I know you think you know where this is going. Clearly, this hapless man could have slipped, and fallen onto the item he was holding. Could have happened to any one of us.

Except that this middle-aged man had fallen onto CORN-ON-THE-COB. With a tenacity available only to the truly desperate, he insisted that he often started cooking his evening meal at the same time as performing simple DIY in the kitchen. He promised to be more careful in the future.

Back in the UK, every hospital I trained at had its own collection of X-rays showing a variety of items stuck up people's bottoms. Some of these items were chosen with a real flair for creativity - or perhaps necessity. But the accidental nature of their insertion was always the same.

Ironically, the only person I've encountered to be truly honest about his "back story" (sorry) couldn't tell us much about it. He didn't know what was up there. In his words, "it could be a vibrator, it could be an aerosol can". At a meeting of like-minded individuals, he had been so out of it that he just didn't know what had been placed inside him.

However good the explanation sounds during the rehearsal on the way to the hospital, the chances are it'll be excruciating for all concerned when it is trotted out in A&E.

In an age where there really are no more taboos, the only surprising thing about the whole repetitive saga is that people continue to wheel out the same excuse rather than just opening up.

Romeo and Juliet

Mrs K was biting her thumb at me. Literally, repeatedly, vehemently, furiously, contemptuously biting her thumb at me.

This small Greek lady did not speak English, but thanks to an admirable display of body language, and my cursory acquaintance with a Shakespearean thumb-based dispute, her displeasure was all too clear.

I had not expected this. Despite 6 years of medical education at two of the best universities in the country, I was flummoxed by this small woman's fury. This fury was a force unlike any other - not amenable to reason, unmodified by calm explanations by Greek interpreters, family members or bilingual patients.

And this was after I had spent the vast majority of my first day as a doctor with her. Because I was determined that my first ever patient would leave the hospital on time, in good health, and with a smile on her face.

On 1st August 2007, junior doctors all over the UK simultaneously took up new posts. The Daily Mail, turning on its head its usual policy of unerring optimism, predicted total chaos. And yes, we did struggle. These junior doctors (still, from my lowly viewpoint, my seniors) were unavailable throughout the day as they sat through a hospital "induction". We were overstretched, overrun, overawed.

But, as far as I know, no patient suffered the consequences. And so my enduring memory will be that of the bilious Greek OAP - my Juliet - disgusted with the perceived faults of her doctor. She left my NHS hospital, under her own steam, less than 24 hours after major keyhole surgery, thanks to a talented consultant surgeon and good nursing care. But not with a smile on her face.

Star-crossed lovers never had it so easy.