The inefficiency of single-person households

Living alone is just wrong. It simply isn’t possible to work (more than) full time and run the household to my own (not particularly exacting) standards. In fact, if I were single (as opposed to about to move back in with my husband, having been separated by work for 7 months), I would probably be hiring a cleaner.  Today was a short (i.e. 9 to 5) day, so I got home at 6:15. Having vacuum cleaned the floor and done some pilates, I then had to do the laundry, check my emails and make dinner (but before that, I had to do last night’s washing up). So by the time I sat down to eat it was nearly 9pm. As for long (i.e. 9am to 9:30pm) days, well, those are the days that result in there being left over washing up and mess. And on those days I just have junk food (or cereal)  for dinner, so I try and have proper food if I’ve arrived home before 7. So much for reading those papers for the research proposal. Or playing the piano. I just don’t have time to keep the house clean and cook as well as have a life/ keep my mind stimulated. And that’s without even trying to have a social life.

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Computers grrr…

One aspect of PICU I have not commented on is the use of electronic patient records. In terms of going through the nursing notes – with automatically calculated hourly fluid balances, urine outputs in ml/kg/h and the facility to plot any parameter on a graph – they were brilliant. Apart from the network being infuriatingly slow  – at times, the speed of the page loading was the limiting factor to how quickly you could get things done. Which is pretty stupid with a critically ill patient. We also used the system for prescriptions, ward round notes and admissions and discharges, so the number of computer terminals (not nearly enough) put a limit on the efficiency of the whole unit. In addition to the general slowness (which was in any case probably due to our servers rather than the software), the ‘medical note’ part of the software was a complete nightmare. To this day I am not sure how much of it was down to the design (which was not brilliant) and how much to the users (who often just didn’t bother to write anything, even though they would have in paper notes).

It took me a while to realise that the electronic record retains the most recent entry (even if it is a few days old) in each field until it is edited, so it is not immediately obvious that the note that appears isn’t current (though it may be headed ‘last 24 hours’), and even when one realises this, it is necessary to click on each previous ‘session’ in order to find out when it was written.  This is partly down to user sloppiness (in paper notes, you would do a 24-hourly summary every day) and partly to software stupidity (how hard can it be to tag the date and time to the entry, and make it appear in the actual text box at each edit).  A typical (and relatively benign) example would be “CT abdomen performed, result awaited”. This tends to be left in the field during the following 24 hours, particularly if the said result is still pending. It is compounded by the fact we all work shifts, so if the scan had been done on, say the evening of 16/1/10, by 18/1/10, the patient may have been handed over to a different doctor twice, maybe 3 times, and the doctor who made the entry might be on a rota’d day off, or night shifts. The obvious solution (which I adopted latterly) would be to enter something like  “CT abdomen performed 16/1/10, formal report expected by 18/1/10”. I just find it ridiculous that a piece of software that can plot the patient’s CRP for the last 2 weeks can’t even tag a date and time to a paragraph of text, and display it in an intuitive way.

But what prompted this post was actually a rush of  ‘computer love’. I’ve just looked up an article in Pediatrics on the (lack of) effect of dexamethasone and glycerol on preventing hearing impairment in children with bacterial meningitis http://pediatrics.aappublications.org/cgi/content/full/125/1/e1, having come across a summary of it in my Google Reader. I wanted to find out what dose of dexamethasone the authors had used. So I clicked on the heading, which brought me to the journal’s website, where I got the full text free. All while enjoying (a rather late) breakfast. [ I am on leave] Not so long ago (when I was in medical school in the late ’90s to early ’00s, in fact), one would have had to head to the library in order to get the full text of any journal article. And Google Reader didn’t exist. So I wouldn’t have been scanning the journals over breakfast at all.

So are we all more knowledgeable then? I don’t know. But reading stuff on my computer at the breakfast table definitely beats trekking to the library. And I’m also ambivalent about computerised patient records. I’d love to help design a software package though. (The user interface, that is, not the actual workings of the thing)

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.

American Psycho – the satire tires

Not related to paediatrics (though a child is among the ‘victims’ of the protagonist) at all, my latest non-medical read is Brett Easton Ellis’s American Psycho. I bought the paperback (along with Kiran Desai’s The Inheritance of Loss, which I haven’t read yet) at a charity shop for 75p. My overall impression is that it would have been much better as a short story.

My interpretation is that Patrick Bateman imagines he is a serial killer when in reality he is some bloke who (I imagine) reads Men’s Health magazine. Or rather, a caricature thereof. The setting of the novel seems curiously ‘period’ to me, as I was only a pre-schooler in the 1980s. I’m not sure that’s one of the effects the author intends; one wonders how much consideration authors give to how their book will ‘age’ at the time of writing.

So Bateman is trapped in his mundanity, in a world where people are identified by the clothes they are wearing – these are described in far more detail than any human characteristics. All his acquaintances seem interchangeable and superficial, the places they frequent all blend into one, and they deliberate over pointless details of etiquette. To (try to) escape, Bateman creates a fantasy world, where he interacts in a physical, intimate and extremely violent way with characters who either come straight out of the pornographic videos he rents, or are people who irritate him in real life. But his fantasies lack imagination, and suffer from his dearth of real life experience – when he decides in his fantasy world to cook and eat a girl he has ‘killed’, he can’t even do it, because he has “never cooked anything before”.

The best part of the book, I reckon, is the episode where the ‘real life’ Bateman gets robbed at gunpoint by a taxi driver. Throughout the book, Bateman is repeatedly mistaken for other people – whether a specific person or “a model”. In this episode, the taxi driver says he has seen Bateman’s face on a ‘wanted’ poster, that he is wanted for killing a taxi driver (one of his fantasy victims is a taxi driver). If that were true, it would be Bateman’s fantasy come to life. But instead of freeing Bateman from his mundane existence, this chance meeting of reality and fantasy ends with him being relieved of his gold Rolex. Of course, like everything else in Bateman’s life, the watch is replaceable (and is indeed quickly replaced, on his insurance). This is, in a way, even sadder than if he had been shot, or had actually lost anything of real value. The novel fittingly ends with Bateman noticing a sign above a door at a bar that reads “this is not an exit”.

So, cool idea, good story. Just too long. Or maybe that was deliberate, to drive home the mundanity of it all.

Verdict: Back to the charity shop. Sorry Mr. Ellis!

(the last book that was a keeper was The Great Gatsby)

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.

Freeze and a recipe

Having spent a week or so looking after babies ventilated for severe bronchiolitis, I have not only succumbed to boredom, but also possibly to the virus itself. Ended up calling in sick (a quite difficult task when you’ve lost your voice) and then falling asleep, not to waken again until afternoon. Felt a bit more alive after that though. So I’ve just had breakfast at 14:00.

It’s snowing outside and the ambient temperature inside the flat is struggling to keep above 15 degrees, even with both heaters going. So it was definitely a porridge day. I’d run out of milk though, so added a splash of double cream, and also the half banana I’d accidently left on the doorstep (just inside the house) – the plan yesterday morning had been to finish it on the way to work, but I’d put it down to lock the door with my free hand, and forgotten to pick it up again. Being impatient, I turned the heat up, and as soon as the oats were bubbling, a smell reminiscent of the Thai desert Kluay buat chee (bananas in coconut milk) arose.  When I last had this at a restaurant, they had topped it with sesame seeds, and it had a salty undertone – a bit like caramel. I didn’t have any caramel or sesame seeds to hand, but I did have ‘Sesame Snaps® with Coconut’, so I crushed one up and chucked it into the pot. And ended up with a Scottish-Thai fusion which I think is perfect for breakfast at 2 o’clock in the afternoon when it’s freezing outside.  Thank you RSV.