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.