Turf to Ortho

A month ago I started writing a rather soul-searching post entitled "Week 1: failures and successes," but only got halfway through before the hurly burly of work and life intervened. I will finish it at some point, but meanwhile, as a bit of light relief, here's a tongue in cheek email I sent to a couple of colleagues after yesterday evening's shift:

Classic House of God style Turf to Ortho today. Two days ago, GOMER escapes from bed, goes to ground in the toilet and NOFs out. Classic.

Almost de-buffs himself, however, by acquiring a PE. I get handed over the organising of the CTPA when I come on, early evening. He's reasonably compos mentis and I get the venflon in no problem. Then an hour later I get a bleep from the radiology reg saying patient absolutely refusing transfer onto table to go through the magic doughnut. My solution is to find patient's wife and escort her halfway across the [hospital name deleted] to talk some sense into her by now unfortunately acutely-on-chronically confused husband who's going absolutely mental in a London accent whenever anyone touches him. (He may or may not actually have been from London.) Well, in the end I persuade radiologist and attending nurses that he's really not currently competent to make a decision about the pros and cons of this particular line of investigation, so let's just wheech him onto the pat-slide and see what happens. All seems to be well as thereafter no-one needs to touch him. Unfortunately though, he pulls off a masterly version of the classic demented gerry venflon-pull manoeuvre (VPM*) halfway through contrast administration (adding risk of compartment syndrome to my accumulating list of de-buffing factors.) I'm all for banging another one in and cracking on, but by now the already perturbed radiologist is completely unglued and in a state of extreme reluctance. So back to the ward we go. Fortunately I'm able to charm the [hospital 2 name deleted] ortho reg into taking the patient anyway, leaving only the small matter of bolusing in some heparin and starting an infusion. Unfortunately this involves getting another venflon into a patient who is by now a total mentalist, maddened up to the eyeballs with NOF pain, hypoxia and gerry-rage. Neither is sedation an option as I'm not going to make friends and influence people by giving him a bit of respiratory depression. So the classic FY1 vs mad-as-a-lorry-old-man Battle of the Venflon commences. I don't know if you've ever tried cannulating a man who doesn't want anything to do with your "fucking crazy needle you fucking bastard what the fuck are you doing to me!?!?!" but it's pretty f*cking difficult, I can tell you. Took about four goes and there was blood on my hands by the end of it but I won, thank goodness, and not a moment too soon as the men in green suits showed up. Phew.

* Said manoeuvre constitutes one component of the classic triad of Keats' Syndrome: venflon-pulling (catheter-, NG-, nasal prongs-, oxygen mask-, stethoscope-, tie- and hair-pulling are closely associated behaviours), an irrepressible desire to escape from the bed/chair/room/ward/planet and an extreme reluctance to become the subject of any medical examination, investigation or treatment (particularly those involving sharp instruments, log-rolling or the unnatural insertion of fingers into bodily orifices.) The syndrome is, more often than not, accompanied by the liberal employment of profanity in the direction of medical staff and/or allied health professionals.

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Speaking of House of God, the unrivalled highlight of my weekend on call three weeks ago was going to see a rather deaf old gentleman with my consultant. It quickly becomes apparent that he can't hear a word we're saying - hearing aids MIA as usual - whereupon consultant says, "Right, let's try the Communicator!" whips off his Cardiology III, plugs the earpieces into the patient and addresses him through the bell-end. Result: therapeutic relationship restored. Marvellous!

Day 1: HAN fail

The nurse had said the patient looked sick, but the first clue we had as to the specifics was a slightly unusual noise followed by the sight of the consultant's skirt and blouse awash with projectile vomit. Prior to the 10.30 meeting, there had been some mention that HAN (Hospital at Night, i.e. the team of doctors and nurse practitioners who staff the hospital between the hours of 10pm and 9am) had seen - let's call him Mr Emmett - overnight. At one point a nurse approached us as we were going round with the reg to say that he wasn't looking too well, but the reg decided to leave it till later - which was now, 11.30. Our consultant was admirably professional in soldiering on, vomit notwithstanding, with sorting out Mr Emmett's immediate problems and providing a model of good medical documentation before remarking that she might go home and change now.

However, it fast became apparent that a rather monumental balls-up had occured overnight. HAN had indeed seen the patient. What they had failed to do was document anything in the notes whatsoever. One makes jokes about getting marks in GCSE exams for writing one's name at the top of the page, but they had failed even to do that. In fact they'd taken an ECG too which, after the consultant had gone, we found buried, unfiled, in an inappropriate section of the notes. They had likewise failed to give the ECG even the most cursory glance with the brains of a 3rd year medical student behind the optic nerves: as well as the tachycardia (accompanied by tachypnoea and low sats, according to the obs chart) it appeared to show right axis deviation. Oh dear. Fortunately for Mr Emmett, one or two things about leads I and III didn't quite add up and a more likely explanation was that this HAN team member had got their left and right confused when putting the leads on. We confirmed this with a repeat ECG and all was once again well with the world.

The thought of the alternative, though, was rather chilling. What if Mr Emmett - an already very ill man - had had a large PE after all and ended up in ITU or worse as a result of a lack of prompt treatment? I think this HAN team member might have found him/herself seeking alternative employment. What's even more frightening is that this wasn't a green FY1, but someone who'd been a doctor for at least a year, perhaps more, or an experienced nurse practitioner. And then you think to yourself: could I ever do anything this ridiculous? Will I?

Graduating

During the intervening period between final results and graduation, it will not surprise the reader to learn that there was a fair bit of calling each other Dr X, Y or Z. Indeed some rather less flattering suffixes were used in reference to antics which best remain undisclosed.

However, for me it was only on graduation day, when it becomes official, legal and proper, that the knowledge of actually being a doctor started to sink in. During the ceremony itself, the pomp and sense of occasion failed to make much of an impression. It was over the following hours, glimpsing myself through the eyes of parents and grandparents, that it slowly dawned on me: the sense of personal responsibility, the weight of lay expectation of what a doctor is, what he should know and be able to do.

For me, the last year has not so much been about getting to the point where the medical school was happy with my level of skill and knowledge as to that at which I was. The former is a bare minimum; the latter is what is required in order to begin any working day with a clear conscience. (Of course, the goal is to end each day with one, but this is rather predicated on starting as one means to go on. No doubt there will be plenty of room over the coming months to reflect on what is at times the unbridgable gap between one's own best and the patient's - and these are perhaps the moments where it is most vital to feel that one really did bring one's utmost to the table.)

As far as this goes though, prior to graduation I did actually feel I had got to this point: I have worked hard over the last year and I worked hard for finals. But standing there, degree(s) in hand, the fearsome realisation dawned on me that this piece of paper, this title - which ostensibly means so much - is worth absolutely nothing more than what remains in the head and in the heart: ultimately one carries nothing more into the ward, operating theatre or consulting room. Underneath our degrees, robes and titles, we are naked.

Introduction

I have recently graduated from a British medical school and will begin junior doctoring, somewhere in the NHS, next month. I hope to use this blog to reflect on what I expect to be a rather significant year. Medicine occasionally affords glimpses of the wheels that turn when both human life and its meaning hang in the balance. Perhaps I will at times succeed in giving an impression of the view.

For my own as well as my future colleagues' and patients' sakes, I will endeavour to anonymise all related events. Names, times, places and inconsequential details are likely to be altered or obscured in order to achieve this.