Friday, 18 February 2011
Saturday, 5 February 2011
Mr Richardson has cancer. He came to us with a history of weight loss and these funny-looking growths under the skin. You don’t need to be a doctor to figure out this diagnosis. We haven’t really done all that much for him other than confirm our suspicions and break the terrible news. He’s been with us for a couple of weeks now, not because he is acutely unwell but because he’s too weak to be safely discharged to his home. The physios are working with him to try and help him build up his strength so that he can walk again, and the occupational therapists are sorting out a whole host of gadgets for his home to help him cope, but in reality they’re probably fighting a losing battle as he grows weaker by the day.
As we approach his bed on our daily ward round, he greets us with a welcoming smile. “Hello Mr Richardson, how are you today?” asks our registrar? “I’m fine doc, thanks for asking,” he replies warmly. A quick glance at the obs chart and review of the nursing notes is all we need to see, and I am happy to record in the notes “patient well, obs stable, plan: discharge planning, medically fit”. He shows us a picture that sits on his bedside cabinet of two smiling children in school uniform. “These are my grandchildren, doc, Lucy is 8 and Tom is 15. They’ll be coming to visit this afternoon and I would love for you to meet them so that I can show them the people who are looking after me so fantastically whilst I’m here”. We all blush, not sure what to say, and the registrar mumbles a word of thanks for his kind words. As we turn to leave his bedside and pull back the curtains, he speaks again. “I mean it you know. You’ve all been so kind to me and I can’t thank you enough for everything that you’re doing.” Tears well up in his eyes and he turns away, not wanting us to see him cry. We oblige, smile, mutter some more and quickly move on. However his kind words have had an effect on us all. We don’t deserve to be thanked, we haven’t really done anything. But it is nice nonetheless to be appreciated and I think that we all have him in our thoughts as we continue to fight through the remainder of the ward round.
Later on that day, at visiting time, I make sure that I take a couple of minutes to visit Mr Richardson and his family. It’s the least I can do for him. I just wish we could offer him more.
(needless to say, all patient details in this post have been amended to a point where everything is completely anonymous)
Wednesday, 2 February 2011
The morning is uneventful and by lunchtime me and my F2 have pretty much seen every patient under our team. Plans have been created and we have a lengthy list of jobs, as well as a mental note of the sickest patients who may require an extra review prior to us going home.
As I return to our own ward having seen the outliers, the ward clerk informs me that our elective patient has arrived. I check the clock, 1.15pm. That's plenty of time to get him sorted out and down to radiology for his procedure at 2pm. The nurses do their stuff first. He puts his gown and wrist band on and all the nursing assessments are completed. Then it's my turn. I have a look over his last clinic letter, head over, introduce myself, take a brief history and perform an even briefer examination. I check the obs - everything is nice and stable. He tells me that he had a blood test at his GPs surgery last week as requested to check the clotting of the blood. A cannula is inserted so that we can give him fluids/drugs/blood should anything untoward happen. I take a drug history and fill out a drug chart and VTE risk assessment. Next is the consent. I run through the procedure, benefits, risks, and what to expect when he goes down to radiology. Does he have any further questions? Nope, he's happy to sign the consent form, and I place it at the front of the notes,ready for the radiologist to sign the consent confirmation. It''s 1.45 by the time I sign my entry in the notes, wish him well and leave his bedside. Oh, one last thing. I should probably scribble his blood tests in the notes and check that he's not likely to bleed out during the procedure.
It is then that I realise that we have a problem. The patient wasn't wrong, he did have a blood test last week. On the computer system I find the results of his full blood count, urea and electrolytes, C reactive protein and liver function tests. Unfortunately none of these tests tell me what I want to know, what is his INR (international normalised ratio - the tendency of the blood to clot). Crap. There is no way that the radiologist is going to do the procedure without the result of this test. There is only one thing for it. First of all I grab a needle and green blood bottle and rush to the patient. Luckily he is easy to bleed and I have my sample in a matter of seconds. Next I ring the radiologist. I apologise and explain the problem. He isn't happy but agrees to wait. INRs can be done very quickly by the labs and we can have a result in 15 minutes or so. Next I give haematology a call. They agree to do the blood test as a matter of urgency and I send the sample their way via the pod system. 20 minutes or so pass and there is still no INR on the system. Getting anxious, I call the laboratory to enquire about the delay. They claim that they have no record of the sample even arriving in the lab. I explain that I personally saw the sample disappear up the plastic tube on its way to the lab and urge them to have another luck. They promise to do so and I leave them to it. By this time the porter who had come to collect the patient had got bored of waiting and returned to his department. Then I get a bleep. It is the radiologist. He is angry and tells me that he is cancelling the procedure as he can't afford to wait any longer. I beg and plead with him, and explain that the lab have the sample and are currently trying to find it. Begrudgingly he gives me another 15 minutes after a lot of grovelling on my part.
I ring the lab back to find out how they are getting on in their hunt. There's no luck so far. Then, just as I'm giving up hope, success! The sample was found. It was processed 20 minutes ago however had been logged on the system under the wrong hospital number, and so it wasn't appearing as belonging to our patient. The INR was 1.1, perfectly satisfactory for an ultrasound-guided liver biopsy. Great! We now have 10 minutes to get our patient down to radiology. First priority is the porter. I interrupt his coffee break to get him back to the ward, then give my new best friend Mr Radiologist a call to tell him that the patient is on his way with an INR of 1.1. We eventually get him down for his procedure with barely a second to spare, everything goes well and he returns to the ward an hour or so later with a smile on his face.
The reason I write this post is not to moan about grumpy radiologists/GPs not knowing what blood tests to do/laboratory mixups. Firstly I think it gives a good example of the day-to-day job expectations of a junior doctor working in the NHS. However also to make a point. One of the worst things about being an F1 is that shit rolls downhill. Whenever someone has a problem, it tends to become YOUR problem and you're left to deal with it. I was desperate for my patient to get his procedure, not just because my consultant would have shouted if he hadn't (he probably wouldn't have done) but because the patient is a really nice guy and I want him to leave the ward thinking how professional we all were and that he had no complaints about his care. Being an F1 involves dealing with a lot of problems such as this, and whilst it's stressful, it is ultimately rewarding when things go well and a patient gets the treatment they need because of your perseverance, determination and ability to grovel to busy consultant radiologists!
Sunday, 5 September 2010
So what's been going on? Well, like I said, I've now been working for over a month as an FY1 doctor in O&G and it's been quite an experience. There have been highs (being successful at every cannula over a week) and lows (missing three cannulas in a morning, bringing my successful run to a quite catastrophic halt). The best thing I've done so far is assisting on a caesarean section on my first morning, and being the person to push a baby out of its mother's abdomen, then cutting the cord. All in all, a very surreal experience and I felt very privileged to be able to participate in this. The worst moments are the inevitable moments of self-doubt - the "am I really good enough to do this?" moments that I'm sure are normal to all newly-qualified doctors. Pharmacy have saved my skin on one occasion (I love the hospital pharmacists - every last one of them!) , and although I was merely prescibing what I had been told to, it's my name on the prescription and therefore my responsibility to check that what I write is correct. I certainly learnt from that experience and will make sure that I'm more careful in future. Also, an angry patient and her relative tried to make me the focus of a complaint when I had done nothing wrong. This was dealt with fantastically by the senior ward staff but it's still confidence-damaging.
My first bleep - that was a special moment of course. I was sitting at a computer in the library going through the mountain of junk emails that the hospital trust sends me every day when it happened. I calmly walked over to the phone outside the library (pulse racing of course - I've never felt more like a "real" doctor) and rang the extension....only to find that it was the ward sister asking me to rewrite some paperwork because it had been done incorrectly. A bit of an anticlimax in the end.
I haven't yet had to do any on-calls. This is because my job in O&G is supernumary (i.e. no one would notice/care if I didn't turn up for work one day) and so I'm not included on the on-call rota. I feel that this is a mixed blessing. When I see my colleagues being bleeped senseless, running about stressed muttering about "post-takes" and the like, I feel a bit left out - a bit "doctor-lite" if you know what I mean. I've put my name on the list of surgical locum F1s and so I hope that I will get to do some on-call if the general surgery rota is ever a bit short and I'm available. There are a handful of us supernumary F1s in the hospital and it seems ridiculous to me. There are unfilled general medicine/surgery F1 spots on the rota and here I am, doing a specialty that I don't particularly like and where I'm not particularly useful. Yet the trust will pay twice my salary to locums to cover the shifts that I would be more than happy to do. And we wonder where NHS funding can be saved...Anyway my next placement is respiratory, widely recognised as hell on earth when it comes to F1 jobs so I shall more than make up for my lack of work at the moment.
That last paragraph makes it sound like I'm sitting around in the mess all day drinking tea and playing snooker. This isn't quite the case. Just because I'm not needed doesn't mean that there isn't work for me to do, particularly on gynaecology where I'm often working 10+ hour days. I don't mind this too much - it's good to be busy and the more time I spend working, the more I learn. So yes, I am working hard, just maybe not quite as hard as the poor souls who are on-call for medicine/surgery.
This has become an epic-length post so I think I'll leave it there. Hopefully I shall update you all again in the not too distant future.