Category Archives: general whinge

Suffering

Suffering for one’s art appears to be a fairly well recognised phenomenon in ‘creative’ circles. But I would argue that suffering for one’s art is a fairly prominant feature of medical practice. I have just spent the best part of my evening crying as I feel really guilty about a young girl whose family are at present receiving her diagnosis of leukaemia. I sent her home from A&E last week, after she had presented with large lymph nodes in her neck and a possible but unclear history of fevers at home. I asked about weight loss, energy levels, foreign travel, immunisations…everything to cover the wide differential diagnosis. I examined her thoroughly, checking for nodes elsewhere and feeling her tummy for an enlarged spleen or liver. We sent blood tests, including a blood film, which showed a borderline platelet count of 128 and reactive lymphocytes. These findings would be compatible with a viral infection, so I sent her home with instructions to the parents to return immediately should she become more unwell. I also wanted her to be seen at the rapid review clinic in a week’s time, and the blood tests repeated. That is where things fell apart. The clinic was cancelled for the next two weeks so I couldn’t offer them an appointment. It didn’t seem urgent enough that I should phone the consultant at home, so I asked them to return to a&e for the blood test and requested an urgent outpatient appointment. I then forgot to alter the plan I had written in the notes. Fortunately, they actually turned up this afternoon, and the blood tests were done. They also got seen by the consultant, who happened to be on hand, but who then told me off for not ringing a consultant at the time. Today’s blood film showed blast cells.

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What I have learned

Have completed the last of my shifts on PICU. The second to last night was completely crazy, starting with a child going onto ECMO; a week-old  baby post-op from an arterial switch operation dropping his blood pressure, an ex-premature baby with RSV blocking off his ET tube and needing an emergency intubation just as a different baby with RSV was admitted from the ward and looked like he was going to need intubation as well. The unit was full, so we were constantly pressured to discharge patients – 2 were discharged to the wards overnight, and 5 were readied for the next morning. One of my patients – a one-year old with polycystic kidneys and hypoplastic lungs, sepsis and ARDS (on triple inotropes and HFOV) was overventilated but swinging her blood pressure with changes in blood pH whenever I adjusted her ventilation, so I was stuck. Another who has been trying to die for the past 3 weeks lost his arterial line and I was tied up trying to re-wire it when the ECMO bed suddenly collapsed. This could have (but didn’t thanks to a nurse with quick reflexes) resulted in the patient bleeding out and dying in a rather dramatic fashion. And at the end of the night we got griped at by the day shift charge nurse for not completing the drug charts for the patients who were being discharged. The consultants seemed pretty appreciative of our work though. The whole thing was a bit like a sequence from the introduction to some medical drama (where all the ‘action’ clips get spliced together), except it was for real, and lasted for 12 hours. It was strangely satisfying though. Not that I would ever do it again.

So at the end of 6 months, I think I’ve learned a few things:

1. Some patients will die no matter what you do [i.e. the ‘critical’ in critical care refers to the condition of the patient on arrival, not to the treatment given on ITU, however much intensivists wish to flatter themselves]

2. If there is a discrepancy between monitored physiological parameters, the least sophisticated one is usually correct

3. If it looks precarious it probably is

4. If the cardiac surgeon hangs about pensively after the handover of the post-operative patient, then there is something they aren’t telling you in the op note [to quote a friendly surgeon, “the op note describes the operation you wish you had done”]

5. You can guess the age of an anaesthetist by his preferred induction agent

6. If the picture doesn’t fit, go back to the beginning [with reference to a boy with low sats who turned out to have methaemoglobinaemia, clearly evident but ignored on his first blood gas]

7. The greatest bravery is in deciding when to stop

Shifts are evil, night shifts doubly so

I managed to hold back my tears until I was away from the Unit. I hate ‘morning handover’. After a 12-hour night shift where you are mostly run off your feet, you have to account for what’s happened to your (often innately unstable and occasionally heroically but inappropriately sustained – see older posts) patients overnight. And sometimes you have to account for what happened the previous dayshift as well, because with the shift system, everyone seems to spend half their weekdays at home recovering from all the weekends and nights spent working. There is a reason why interrogating exhausted, sleep-deprived subjects is an established form of torture. At the end of the shift one is tired and hungry. Every blink threatens to turn into an hour-long nap, and arms and legs, even thoughts are leaden. I slump into the ‘handover room’, careful to avoid the eye of the mother of the boy who was admitted with an out-of-hospital cardiac arrest. Any empathy that flows from me now will cause me to crumple. I care about my patients (that’s what makes this job so painful), but I have been hassled to within an inch of my life for 12 hours, and at that moment I no longer have the capacity to care about anything or anyone anymore. And then in that room, they question you about decisions you made, decisions you didn’t make (perhaps even disagreed with), argue among themselves, burnish their egos, while you fade away…. and then they yell at you to speak up. There is no appreciation for your work. It is torture. I can’t believe I’m going back for more. (It’s called Professionalism.) I really really hate this job. There is no way I’m ever working on an intensive care unit again.

It’s Monday!

I love Mondays. Mondays that I have off after a weekend on call, that is. Or even, Mondays when I’m working, but no longer on call, freed from the tyranny of the Bleep.

So the end of my time in intensive care is looming. That’s a good thing in general, I can’t wait to get out of here. But I’m worried I’ve not done enough Procedures. That is, tracheal intubations, central line insertions, chest drains (basically sticking tubes into places where there are orifices, or none). Since my ambition is to become a neurologist who spends most time in academic work, I don’t really need to be as slick as, say someone who wishes to become a consultant in emergency medicine, or an anaesthetist. And if truth be told, though there is a certain satisfaction when the blood/carbon dioxide/pleural fluid etc gushes out of a correctly placed line/tube, I don’t particularly enjoy doing these things. Unfortunately (both for me and for my patients), I still have to get signed off as ‘competent’. What I hate most is the feeling of preying on the (literally) vulnerable in order to clock enough of these things up.

At the start of the ITU shift, all the doctors (we are called ‘fellows’) gather around the patient board and divide up the patients. It can be quite tactical, with whoever is likely to need an arterial line or chest drain being most sought after, and whoever is ‘not for escalation of care’ the least favourite. However, one has to consider one’s relationships with colleagues (don’t want to antagonise them too much), and the fact that most of the patients are really complicated, so it is better for them to have the same doctor, at least for a few days where (the doctors’) shifts allow. Being a mild, accommodating type, I usually get the bum end of the deal. Hence my lack of ‘procedures’. I don’t think it’s all quantity though. I think there is a certain critical point when something becomes an ability (a bit like the moment you can suddenly ride a bike).  So I reckon I’m able to intubate now.  Anyone, of any size, orally or nasally, whether they have teeth or not (this may sound bizarre, but teeth were a big thing, because I started off doing babies on the neonatal unit).  Apart from the officially categorised ‘difficult airways‘. But that’s anaesthetist territory.