Unpublished elective posts: My first solo ward round!

Unpublished elective posts part one

Foreword
A few years ago I published posts from my medical school elective in Tanzania whilst I was out there (see 2011 around september time in archives).  I used to write them in the evenings on my PDA and then publish them as and when I was able to get access to a computer.  As my elective was in a very rural village this was quite sporadic - the hospital did have one computer but being the only computer for a hospital of 120+ patients it was frequently in use and even when you could get access to it (usually late in the evenings if you could find the key to the computers room) the internet could be outpaced by carrier pigeons and power cuts were very frequent meaning I often lost blog posts and emails halfway through trying to send.

The upshot of this is that there are several partial or fully written blog posts lurking on my computer that I never published.  Its difficult now to publish the partially written ones as the me that would complete them now already feels like a remarkably different person to the wide-eyed enthusiastic fourth year medical student who was getting frustrated by the level of care given at the hospital and the memories of that frustration have already begun to fade.   But, I will try and slowly publish these posts and stay as true to the thoughts I had at that time because my elective remains my most enlightening medical experience and so the most worth blogging about in my opinion.   I will say with each post whether it has been partially written in recent times so you can decide for yourselves how accurate to my experiences at that time the blogs are.  I won't delete bits of the blogs however much they make me cringe now!

My first solo ward round! (minor additions to first paragraph only)

5.10.11

Accidentally ended up finshing up a male ward round by myself today because the clinical officer had to go to opd and asked me to see the last few patients.   Pretty strange having two nursing students plus 1 qualified nurse following me and pushing the notes trolley; I am used to being the ward round follower or notes trolley pusher!  This entourage was definitely useful though in terms of taking a history when I do not speak swahili! This translation service wasn't completely useful however as clearly there are boundaries out here that we wouldn't feel were appropriate within a medical setting in England.  For example the nursing students refused to translate "When were your bowels last open" and giggled at the very suggestion.  Unfortunately this question wasn't really something I could charades-style act out...

In total it was only a few patients that I had to see on my own, but think I did manage them correctly and even noticed that a patient who appears to have had a stroke secondary to hypertension has not actually received his prescribed antihypertensives for the last 3 days, something which has not been noticed in the last 3 ward rounds! So feel pretty proud of myself really, maybe I will make a doctor yet!

Rest of day was pretty full of responsibility as well.  In maternity ward there was a patient in the labour room with poor progress of labour who was on an oxytocin drip which was supposed to be given at an increased speed every half an hour, however despite the fact that there was 3 midwives about plus an insane number of student nurses, every time I popped into the labour room from ward rounds the increase in speed would be massively overdue and still not done! So had to do it myself as well as go on two ward rounds - multitasking skills!

While I waited for the doctor to come and review this patient after the oxytocin had failed to increase the strength of her contractions, I watched the nursing students being taught how to perform a vaginal examination of a pregnant woman.  Craziest teaching of a pv exam that I have ever seen!About 20 students all round one patients bed whilst the teacher performed an examination this intimate examination on her! Poor patient! Talk about intimidating! Also some of the smaller girls standing at the back clearly couldn't see so I'm not sure how much they learnt from the experience. Very, very different to how this is taught in England!

The examination - there are two pregnant ladies within this corner - the one that is being examined and one nearer the camera that students are leaning over in order to see the examination

Halfadoc x

The unwritten rules of being a junior doctor/ 25+things you wished you knew before becoming a doctor

Well I thought it was about time that I did a junior doctor version of my post about things you wished you knew before starting medical school ( http://halfadoctor.blogspot.co.uk/2012/06/80-things-you-wish-you-knew-before-you.html ) so here goes:

1. (And this is the most important) Never say the "q" word. The q word is the dirtiest swear word of the medical world. In the rare event your day is "Quiet" DO NOT SAY IT!! If you do utter the word then be prepared to be blamed by all staff when seemingly every patient on the ward becomes deeply unwell.

2. When referring a patient you can prepare your referral as much as you like and still guarantee the senior you are discussing with will ask that one aspect you forgot to look up such as the all important serum-rhubarb level.

3. Crash bleeps like to go off when you are in the middle of a procedure or breaking bad news

4. Crash bleeps like to get cancelled as soon as you arrive at the correct location having run from the opposite end of the hospital.

5. As per above "crash call cardio" is an excellent way of getting your recommended exercise.

6. The patients you get called to see with low urine outputs/ poor oral intake will probably have drunk and/or peed substantially more than you have during your on call shift.

7. You will have to make some truely awful referrals/ investigation requests at the recommendation of senior doctors (surgeons I'm looking at you) and by the end of your fy1 year you could probably make a decent second hand car salesman after the amount of shit you have been peddling to other specialities all year.

8. For the above the words "my consultant would like" absolves you from blame for crap referrals.

9. You will get blamed and/or shouted at for the crap referrals anyway.

10. A great ward sister/ charge nurse who likes you will make your rotation survivable. Doubly so if said nurse is also an avid ward baker.

11. You will just be finding your feet in a speciality when you rotate to the next one. Return to go, do not pick up 200.

12. The most difficult to bleed patient will also be the one who needs daily/ twice daily bloods.

13. You won't have to do a female catheter until there's a patient that none of the nurses can catheterised and then suddenly you are expected to be the expert...

14. If you are a female doctor then in spite of your stethoscope neck adornment and totally different dress code you will get called nurse by patients 85% of the time.

15. To misquote pirates of the Caribbean: Your finish times are more like a guideline...

16. However late after your shift it is if you are on the ward you will still be considered fair game by other staff for more jobs.

17. As soon as you have qualified (if not as soon as you have started medical school) be prepared to be accosted by nurses/HCAs/cleaners/catering staff/ friends/ family/ the cousin of the great great granddaughter the lady who lives 3 houses away requested you look at and instantly treat their rash.

18. All rashes look the same to an FY1

19. The treatment for most rashes is emollients and/or steroids anyway.

20. You will develop a robust stomach that cannot be touched by indigestion. This is because you will strengthen it by consuming a lot of your lunches either whilst fast walking between wards or while typing a discharge summary with one hand and eating with the other.

21. If you start reviewing a patient whilst eating lunch however you may have gone too far.

22. Most of your friends will be doctors.

23. You will spend a lot of your social time discussing medicine with other doctors.

24. On the rare occasion you manage to venture away from the medical crowd for socialising please see point 17. You will still find yourself discussing medicine...

25. Scrubs are lifesavers when laundry day came and went about a month ago.

26.  You will find a pair of comfy shoes and wear them to pieces as the thought of breaking in new shoes on the wards is unthinkable.  (In my case I wore my shoes until there was decent sized holes in the soles.  I only threw them away when I stepped in a patients vomit...)

27.  You will develop a creepy habit of staring at people with bulging veins and thinking "phwoarrr how easy would it be to cannulate that!"

28. Your patients will rarely have such veins.


I will add more "rules" as I think of them

Dr Halfadoc x

Rubbish Handovers

Doctors are often slated for their terrible handovers between shifts.  Whilst nurses have a rigid formal handovers at every shift change, we have formal handovers between SOME shifts but informal between others (for example the day doctor may bleep the twilight doctor with something that is yet to happen such as blood coming back, this is often quite haphazard. The twilight doctor will then formally handover at the end of their shift in a sit down meeting to the team of doctors on overnight including senior doctors.  I've noticed Often the very minimal change of sitting down and having someone senior present improves the quality of the handover and how much information is given.  However the twilight doctor may be handing over stuff from the day teams list so their handover will be limited by what the day team originally told them.)

Here's a handover I recieved this weekend:

Night shift doctor :  Oh and Mr Y hasn't had his xray yet.
Me: What is the xray for?
Night doctor: Not sure
Me: ... What type of xray
Night doctor: Oh erm Chest xray.
Me: Ok can I have his hospital number
Night doctors: (Has this and gives it to me but only after I ask)

I later hunt down Mr Y's request form purely so that I can find out why he is having one.  At this point I discover its not  a chest xray but a lower leg (fairly different ends of the body!) and he is having for the potentially very serious issue of ?osteomyelitis (infection of the bone). So I was very glad I looked!

I received this handover at a formal type handover so perhaps sitting down doesn't always solve "medical-chinese-whispers" after all.  In summary, we as profession do need to work on our handovers.  (This example is the worst I can think of but there are plenty of other slightly rubbish ones).  This weekend has reminded me about the importance of trying to both handover well and make sure I ask the right questions of those handing over to me so that I know what is going on.  Geeky though it is I recommend all those reading this try to remember to do their handovers in a formulalic way such as the "SBAR" system.

Happy handing over!!

Halfadoc x

Bedside manner anecdote part 1

Me attempting to calm down very angry and aggressive patient: (About 4th attempt at explaining to the patient that she has had an intracranial haemorrhage which is why she needs to be in hospital and that she needs to calm down (stop punching us!) so we can examine her) So the reason you are in hospital is because you became unwell at home so your husband has brought you in, your brain scan has shown you have had a bleed on your brain.  Do you understand this?

Angry patient: Well you dont even have a bleedin' brain!

Well played patient, well played.

The reality of life as an FY1

So I'm now in my tenth month as a foundation year doctor working at one of the busiest hospitals in the country (great job picking there Halfadoc!) . I'm not going to apologise for having thoroughly neglected my poor blog even thought its something I never intended to happen and gives me the occasional sharp guilt pang before I forget about it again (probably due to being distracted by remembering another of the 1 000 000 life tasks I have forgotten to do).

The reality of life as a junior doctor is that at points of the rota I am so busy, so tired that I scarcely can summon the energy to do the bare essentials of eating and washing before I go to bed.  This isn't deliberate hyperbole and I do not think it is that far from the truth at times.  It isn't the entirety of life as a junior doctor either but when on the "easy" rota shifts you often find you need to spend your slightly increased spare time catching up on the washing you neglected during busier patterns, attending own health/dental appointments, paying bills, hoop jumping for the dreaded e portfolio (an online method of assessing Junior doctors  using a series of tasks that are about as useful as the labours of hercules) paying in ash cash cheques (not all chores are bad!) etc etc.  The remaining spare time not surprisingly you often feel like spending as selfishly as possible ;). I used to be reasonably keen at playing sports (albeit in a lazy halfhearted kind of way).This year I have attended exactly one training session and one competition - in which I came second to last in, I guess the lack of training has caught up with me.    So that is why my blog has been neglected badly enough that if it were a patient in the NHS it would probably have gain a DNAR (do not resuscitate) form by now.

So is it all bad?
No. But you have days/weeks when it feels that way.

However there are moments that bring you back and make it feel worthwhile again and here are a few examples to stop this post sounding all doom and gloom:

• Mrs Jenson, the lovely old lady who recently submitted to me cannulating her with a stiff upper lip that all too few of the patients have and afterwards thanked me for doing what is after all a painful procedure (though not as painful as some patients suggest) and gave me a handful of her chocolates as thanks.  She wouldn't take no for an answer and I was very grateful for her as that handful of chocolates was in fact the total of my lunch for that 12.5 hour shift.
• Mrs Smith, I met this lady whilst they were in the surgical high dependency unit where I was the sole junior doctor for a nerve wracking few weeks.  She was there throughout my time and had a really rough time of it.  She'd had a surgery to remove a bowel tumour which had left her with a stoma.  Unfortunately the stoma wasn't working and she had a condition called Ileus which basically means her remaining bowel had gone on strike.  This is very common after bowel surgery but this poor lady had it worst than most.  She was in high dependency for weeks, required a repeat operation after a leak from where she her bowel had been joined up at which point she developed prolonged ileus yet again.   She was very ill and very low in mood and yet in spite of this had her relatives bring in regular chocolates for the ward staff and once even summoned me over and gave me a box of chocolates and said it was just for me for the help I had given her (naturally I did share it with the nurses as I had certainly nicked theirs to keep me going through skipped lunches).  She also used to say "god bless you " to me on a regular basis which as an atheist made me feel a bit guilty but I appreciated the kind sentiment.  This lovely lady fortunately did go home shortly after I left the unit.
• The adrenaline rush of a crash call and amazing feeling when the patient DOES regain an output.
• A thank you from a healthy patient who is going home.
• Pay day.  I didn't do medicine for the money and theres a lot of better, easier ways of earning the same or more and definetly earning more per an hour.  However when times are tough and you barely can keep going at least it is a day to focus on.

(As ever all names/ details have been changed.)

Lately I've been re reading Max Pembertons junior doctor book and realising what an accurate portrayal it really is of life as a junior doctor. I read it before medical school, and I thought I understood what he was saying and what being a junior doctor would/could be like, but I'm now not sure you can until you are really there.   I don't think even medical school fully made me realise what it would be like.  I particularly however liked this quote from his book: "I was never naive enough to think that medicine would be a bed of roses, I just never realised there'd be so many nettles" 

For this weekend however this fy1 is enjoying the sunshine safe in the knowledge of impending annual leave and the e portfolio finally being handed in.

Till next time,

Halfadoc x