12 all out

An hour ago I handed over my on-call bleep to a (disgruntled) SHO about to start her night shift. This act signalled the end of a 12 day stretch of shifts. I should be pleased (indeed I am), but right now I don't have the energy to celebrate too much.

The Monday before last, I came into work with a smile on my face, full of enthusiasm. We were one SHO down on our team as she was working nights but we would manage just fine. The consultant ward round that day went smoothly and the jobs were done by 6pm - a good finishing time.

The next day we were without a registrar, but we coped. I even had some excitement, correctly diagnosing a benzodiazepine overdose and reversing it with flumazenil, impressing the nurses and medical students in the process.

As the week wore on however, we started to flag. The work load was increasing, patients seemed to stop responding to our treatments and our finish times were becoming later. By Friday I was well in need of a rest. The "Friday feeling" was very much evident on the ward that day - everyone looking forward to the weekend. Everyone, that is, apart from my team, as we had a weekend on call approaching with alarming speed.

So the weekend was spent on EAU, clerking the new medical admissions. I love this, it's medicine at its best. Be the first doctor to see a patient, stabilise them, do some initial investigations and start some basic treatment. Any problems and you have EAU consultants and 2 registrars to give you advice. Saturday was chest pain day. Lots of ECGs and troponins were done, but I made no diagnoses of ACS. We had 19 patients on the post-take list. Sunday was less busy with 16 patients clerked, but we had some proper sickies. I went off to see a ?NSTEMI on our cardiac care unit, only to find that it was actually a STEMI and needed thrombolysis. Very exciting stuff.

The weekend itself was alright but I was well and truly shattered on Sunday night. Unfortunately I had to do it again on the following Tuesday, on call with another team for the day - my 3rd 13 hour day in 4. This was also my birthday and so I was hardly pleased to spend the majority of it in EAU.

Our list wasn't getting any smaller and our next take was getting ever closer. Thursday I was on the ward alone whilst my SHO and registrar went back to EAU to clerk some more patients. They even stole my med students, who (unsurprisingly) found the prospect of clerking new admissions more exciting than ordering scans and bloods for me on the ward.

Miracle of miracles, we managed to get rid of all our patients that we took yesterday (short stay cases stay under the EAU consultant) and our list remained at 25 patients. And so roll on Friday - day 12 of 12. Registrar-led ward round, we finished by 1pm, but we had a LOT of jobs to do. This afternoon was utter chaos. I've removed 3 chest drains, pleurodesed another drain, done 3 cannulas, taken 7 sets of bloods, discharged 3 patients, done 3 TTAs for the weekend discharges, checked 6 chest x-rays and made 2 referrals.

And, just to finish off the stretch, I had another 13 hour day today. Ward work finished, I headed off to switchboard to pick up the ward cover bleep, being the first point of contact for 9 medical wards from 5-10. Luckily it was a quiet night. My biggest concern was a hyperkalaemic patient with poor IV access but we sorted it eventually and he got his calcium gluconate and insulin before he had chance to develop any funny cardiac arrhythmias. Come 10pm I practically threw my bleep at the poor night SHO.

So yeah, right now I'm drained. I literally have no more to give. I love this hospital and the town it's in, but I need to run far away to recharge my batteries. So at 6am tomorrow morning I shall be on the first train back to Manchester where I can go and think about something other than medicine.

Appreciated

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)

My problem

As I walk onto the ward this morning, our ward clerk calls me over. "Just wanted to let you know that Dr X (the consultant) has an elective admission this afternoon for a ultrasound-guided liver biopsy. He's booked for 2pm and will be here by 1pm." I thank her for the tip and make a note of the patient details on my list, mentally running through what it expected of me when he arrived.

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!

Not dead!

Wow, has it really been a month since I wrote that last post? That means that I have been working for a month as well. I guess that I underestimated just how busy I would be and this blog has been pushed to the background. I would promise to update more frequently from now on but it would be naive of me. The thing is, I just don't have the free time that I was accustomed to as a student, and when I am free, normally sleep is the thing that comes to mind, not blogging. Make no mistake, I'm going to keep this blog going, it's good to know that it's there when I have the time. Just don't expect daily posts, that's all. I'm going to aim for a "quality, not quantity" approach I think. Whether I succed or not, I shall let you, the reader, be the judge...

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.

Simon

And so it begins

Sorry that I haven't written the second part of my post on medical school, I have been extremely busy these last few weeks. The second part will be written, I promise. I just need to wait until everything has calmed down a bit first so I can concentrate.

Tomorrow morning I will be the FY1 doctor for obstetrics and gynaecology at this hospital. The shadowing period over, I am going to be flying solo tomorrow for the very first time. Obviously I will be supported by my senior colleagues but I will no longer have someone looking over my shoulder every second of the day. What's even scarier is that I am expected to know stuff! O&G has never been my strongest subject and I really hope that my ignorance isn't exposed too much.

Anyway, I'll leave it there. Wish me luck tomorrow and hopefully next time I write, the body count will still be at zero!

Simon

Thoughts on leaving medical school, part 1

Now I have graduated I thought it would be a good time to look back over my time as a medical student and share some of my thoughts and experiences with you all. I'm going to focus on my time at Manchester rather than spend too much time talking about my St Andrews days, since I think that it is the last three years that have given me the most to think about and reflect upon.

I will make no secret of the fact that I am not a fan of Manchester medical school and I shall attempt to explain why in the following paragraphs. However I don't want this to become a rant, and for this reason I have found it a hard post to write (this is my third attempt at doing so). So I would like to start by acknowledging how lucky I am to have received a medical school education and I realise that there are thousands out there who would give almost anything to do the course that I have just completed. I also accept that there were some things that were great about Manchester. For example, I loved the fact that we were given 10 weeks to produce a piece of clinical research at the end of year 4. I learnt a lot about myself and my future career from this. Also, the online course management system at Manchester (MedLea) is actually pretty good. The techs love to fiddle with it all the time but it works well and provides a great infrastructure around which the course is based. There are other aspects of the Manchester course that I could praise as well, including some fantastic members of staff. I do appreciate my time here, and I'm grateful for the opportunities that I have been afforded.

Right, now I'm going to talk about what I see to be some of the less good aspects of the course. Let's start with a fact. The medical school here is BIG. There are about 450 students in my year and this, in my opinion, is too many. We are split over four teaching hospitals. Three of these hospitals are in Manchester and one is in Preston (about 40 miles away). So we have four groups of students all being taught independently, however they are all under the banner of University of Manchester. It doesn't take a genius to see that there are going to be problems setting equal standards across the board in these cases. Each base hospital approaches things in a slightly different way and therefore there is considerable variation in what each batch of students are taught. Before writing this, I spent some time looking at exam results in each of the sectors and it didn't surprise me to see that the number of students failing the January exempting exam (final exam) was by no means evenly distributed across the four hospital sectors. From this it seems apparent that some students are receiving better teaching/advice than others and that doesn't seem fair to me, especially as all the students applied to the same university.

Another disadvantage of the university being so big is that it seems very impersonal. In St Andrews the staff knew each student by name and genuinely wanted to help us achieve our goals. In Manchester each student is seen merely as a number, another punter passing along the medical school production line. This has a huge impact on student satisfaction. According to last year's National Student Survey, Manchester is the lowest scoring medical school in the country for student satisfaction (61%, the next lowest is 67%). Medical students are like puppies, we like to feel loved, and at Manchester we are just one of the masses. The feeling that you get is one of "so what if you fail, there are plenty more where you came from". I feel that the best way that this problem can be solved is by cutting back on the number of students admitted, and making the medical school more small and personal. Perhaps the Preston students could break away from Manchester and form their own medical school? There is a decent university in Preston and I'm sure they wouldn't say no to a medical course in their prospectus.

This post is already reaching epic proportions so I am going to leave it there for now. I do have more to say though. In part 2 I will write about the teaching and organisation of the course here in Manchester. This will hopefully be up in a few days so check back soon.

Graduation

So there we have it, it's official. I am a doctor. Wednesday was graduation day and the piece of paper that I received means that I am now Dr Simon MBChB BSc (Hons).

Almost as importantly to me, graduation also signified that I am no longer a student. More specifically I am no longer a student of the University of Manchester. I'm halfway through writing an epic length post about my experiences of medical school but let's just say for now that, in my humble opinion, the course at Manchester leaves a LOT to be desired. I shan't be sad to say goodbye to this university at all.

When I graduated from St Andrews three years ago, only my mum and sister were able to attend. This time my dad managed to get the time off work so that he could come along as well, and it was nice to have both parents there. The day started with a trip to the "robing room" to collect my gown and hat before heading to a marquee for the medicine garden party. This was an excellent opportunity for photographs with friends and family and it was nice to catch up with some people who I hadn't seen since I went on elective back in March, as well as to meet my friends' families. My little sister (15) took advantage of the unattended alcohol and helped herself to the complimentary champagne. I've never been more proud of her, she's obviously preparing herself for student life early!

After the garden party, the first half of the year went to their ceremony whilst those of us with surnames in the second half of the alphabet had time for lunch. I also spent well over an hour queuing for my "official" photograph, which will soon be hanging somewhere in the hallway of my parents' house I'm sure.

The ceremony itself was rather underwhelming to be honest. I loved the pomp and ceremony of the St Andrews graduation ceremony. This was much more business-like in comparison. There was no singing of the "gaudeamus", and everything was in English rather than Latin. I was particulary disappointed with the graduation address, given by a high-up in the university. It served as no more than an advert for the university. The essential message was "well done, remember how great we are for giving you this degree, please give us donations in return". The address at the earlier ceremony was apparently even worse. The poor students were given a telling off, and lectured about all the people round the world who would never have the opportunity to study for a degree. I'm sorry but a graduation address is supposed to be the time to celebrate achievement, and these two speeches definitely dampened the mood a bit.

I managed to walk up the steps, shake hands with the presiding officer, and back down the stairs again without tripping up and very quickly it was all over. After taking an oath (a modern version of the Hippocratic oath), it was time to put our hats on and join the academic procession. It was really nice to see some of our old lecturers from St Andrews that had come down to see us graduate. They looked so proud when one of their ex-students stepped onto the stage. Another great idea was that the university broadcasted the ceremonies live on their website. This meant that my auntie in Australia was able to watch from her bedroom (it was 2am over there) and see me graduate.

On the whole I enjoyed my day and I will give credit to the university for doing a great job of organising it all. Whilst the ceremony wasn't to my liking, I guess that St Andrews was exceptional and that Manchester was the norm, and so I can't criticise really. I now have one more week of holiday before I start my shadowing on the 27th July. I am excited and terrified in equal measure!