Jo came in with some chest pain today. Sudden, central, radiating to her arm and jaw. Classical MI. A and E did an ECG and it showed some changes that showed they heart was under strain, and that she was having a heart attack.  It took a few attempts to get a good trace because she was in so much pain she kept moving around. The A and E reg wasn’t too sure whether or not these changes were definite evidence of an MI or not. The changes needed to be at least 1mm in 2 different places, and they were only just 1 mm. They could have been due to some other things. They could have been present on every ECG that Jo would ever have. They wanted a second opinion – should they thrombolyse?

I looked at Jo  – she certainly looked like she was having a heart attack, cold clammy with central crushing chest pain. I looked at the ECG, if you looked carefully two leads showed just 1mm of changes, and some changes in other leads as well that support it.

‘Lets do it’

‘I’m afraid you’re having a heart attack, we can give you this treatment to break down the clot in the artery but it can cause bleeding and it can cause strokes’.

No one is in a good state to give informed consent when they feel that they have an elephant sat on their chest. You can’t go and research your options on the internet. All you can do is leave it to the doctor standing in front of you to hope that they are right. She trusted me. I was the nice doctor who had just given her the nice morphine that relieved her pain.

We didn’t have any old ECGs, so we had to assume that Jo’s old ECGs were normal, and the changes we were seeing were new. We would only know for certain in 12 hours time when we did a blood test, a troponin to see if there was any damage to the heart. Thrombolysis is an incredibly effective treatment, it will reopen the artery and increase her life expectancy. But it could kill her, it could cause a stroke or fatal bleeding. High stakes but effective. Compare that with  homeopathy where you don’t do much harm, but are unlikely to do much good either. We could cause her to have a stroke for no potential benefit to her heart. If we don’t give it when we should we would deny her a chance of living without heart failure. The ECG will stay in the notes so that people can look at it forever more and tell me if  I did the right thing. I imagine myself standing in the coroners court explaining why I gave a treatment that killed her.

Actually giving it is a bit of an anticlimax. Just a little injection into the cannula.

But the ECG remains in her notes for ever more, so people can pick it up and suck air in through their teeth and decide if I did the right thing.

I’m writing this from the office of the renal ward where I work on. It’s my last night as an SHO in Medicine and from tomorrow I’m about to be a Registrar.

A registrar is the second in command in a team of Doctors, at  night they are the most senior doctor in the hospital. Starting out as one is pretty scary actually. I’ve been locuming as a Registrar since I passed my MRCP last year, so some of the fear that I felt at first has dissipated.

I couldn’t decide what sort of medicine I wanted to do. But I knew what I wanted to be – the sort of generalist who can make the diagnosis that no one else can. Basically I wanted to be Dr X from a certain hospital.

Working for him was like working for House  MD. You do watch House MD don’t you? You really should. He was the best general physician I had ever met.

He was an endocrinologist. But endocrinologists aren’t generalists any more – in fact most single organ ologists do tend to have a bad habit of looking at the organ rather than the patient. I want to care for patients not organ systems.

So I decided to be a Geriatrician. We’re the last true generalists. And as of Wednesday I start my specialist, or should that be generalist training.

I’m planning to use this blog to post interesting things about my training. I’m also hoping to write about interesting journal articles and other topical things in Medicine.

We got back for holidaying in the far north yesterday. As is a feature of holidays in the remote north the weather gets better when you arrive home. I arrived home in a glut of holiday traffic going towards a more popular holiday resort that the one I went to.

I also arrived home to a letter annoucing that I am doing PACES on the 29th of October. Eeep. When I went to buy some milk in Tesco I found a colleague who also has his PACES date and we agreed it was time to start work.

I did do some ‘bookwork’ on holiday and it was ok, though I could have done more of it of course.

I’m afraid I’ll be off for two weeks. Please don’t loose interest! I’ll be back in two weeks time.

An ICD in a strangely muscular person. Usually they are in fat unfit people. Like me.

An ICD in a strangely muscular person. Usually they are in fat unfit people. Like me.

The first time I heard of implantable defibrillators, during a tutorial at medical school. I thought they were possibly the coolest thing I had ever heard of. They seem such a great idea.

There are some people, we know, who are at risk of sudden death. The people who are high risk – for instance the ones that have just had a heart attack – we don’t let out of sight of a defibrillator. This is because they are likely to have a sudden arrhythmia that can easily be shocked into sinus rhythm.

So we have to let them out eventually – but there are certain people walking around who have a higher risk of sudden death. We can try and have a defibrillator in all places, and we can make the ambulance service respond quicker. But unless you keel over right next to a defibrillator your chances of surviving an out of hospital cardiac arrest without severe hypoxic brain damage are pretty low.

I know that this stuff can occasionally work and save lives. I can remember the patient I admitted from A and E with a heart attack who had a cardiac arrest in the waiting room. After one shock he was back and had his primary angiogram 20 minutes later.

So there’s the great idea of putting a defibrillator into people, in the same place a pacemaker would go. If you keel over and have a fatal arrythmia it shocks you back.

The other thing to remember about them is that if you are removing them from dead people then if you don’t turn them off you get third degree burns. The mortuary attendants love to wind you up and tell you they can’t remember if it’s been turning off or not when you are removing them.

Anyway – then I met a few people who had them in. And they were all slightly strange, especially if they had been shocked. The ICD (as implantable cardiac defibrillators area called) seemed to drive people into a constant state of anxiety. Or at least the ones I met were in a constant state of anxietey.

So I was interested to read a study in the New England Journal of Medicine about the affect of ICDs on quality of life.

It’s a good study and a large one. It compares the quality of life of people with ICDs to people who are on Amiodarone, which is one of the alternative treatments. So by and large people have a similar quality of life. However people who have recieved a shock from an ICD in the preceeding month do have a worse quality of life than those who haven’t. Presumably those who are in the Amiodarone group who would have recieved a shock had they had an ICD in would now be dead.

However it doesn’t cover the times when people are most distressed by ICDs- when they’re going off an lot.

And also when you’re dying of something else and the ICD had to be turned off. Otherwise your dying moments would involve a sensation that apparently feels like being punched in the chest – repeatedly. But the decision to turn off the ICD can be distressing for a family and a patient.

ICDs – along with many other things in medicine are fab , but the give us choices. And they give us the choice to turn them off, which can be a hard one to make. Then of course do you want to die suddenly and painlessly of a cardiac arrest or slowly and breathlessly of a heart attack.

What about when you have a severe stroke and are admitted to hospital with pneumonia – do you want to still be shocked back. Because the quality of life you had in a nursing home wasn’t great was it?

I have to admit I wouldn’t really want an ICD if I was in that situation – or maybe I would. It’s hard to tell unless you’re there isn’t it?

Yesterday was my day off, we get a random day off prior to our nights. As in I have Thursday off and start nights on Friday. The reason for this, I suspect is to keep our hours under the prescribed 48 in a week rather than out of any particular concern for our welfare. Anyway I don’t always take this day off, especially if I feel that it will leave the ward understaffed and put the patients in danger. I am an annoying prig like that.  I usually take the ‘day off’ some other time when it’s less dangerous for patients.

But today the rest of my team was there, I left my, actually very good HP (house plant) with The List and my mobile number, (control freak – me?). I spent the morning pottering around the house and went into work to do some work on The Audit From Hell. I was feeling all hopeful that I could finish it today and be free from My Audit Hell. I had a coffee, a gossip with my secretary.

She wonders why I am here on my day off. It’s because I’m not going to get any auditing done without doing it in my own time.

Anyway I start to photocopy some more proformas, quitely because there isn’t any budget for photocopying for audits. My house officer bleeps me with a question, I answer it. General Office bleeps me and asks me to fill in a death certificate that ‘no one else can do’. I do it – we get paid for these independently so I don’t mind going in on my day off for that.

I finally sit down and start going through some case notes. So far so good, then I get bleeped again. It’s a nurse, she’s paniking, one of our patients is sick. She’s not taken the time to look at the rota – why should she – it’s a massive Excel spreadsheet and takes ages to open. She looks slightly surprised when I turn up on the ward wearing combat trousers, walking boots, and a tee shirt. She goes all apoligetic and offers to get another doctor.

Partly because I’d rather be fixing sick people than messing around with paperwork, partly because I’m there. I see the patient anyway and manage to do some of the initial things and start to get the patient better. The nurses are at the stage where they are doing every thing that I say, two of the student nurses are providing everything that I need as soon as I ask for it. I actually like looking after people who are this ill, I like the way that a team works together with a common focus. I have enough confidence in my skills to be able to know what to do, and there’s still people more senior than me on site to call if I can’t deal with it. Until recently the fact that I am alone with a sick person would panic me, when I am a registrar and realise that the only help is a consultant at home I will be panicked. But now I can do it and I’m ok.

Finally 1.5 hours later and we’ve got a plan, the patient is stable, the family are aware, I find my Registrar who emerges from clinic and explain what I’ve done. Then he sends me home. Or actually back to My Audit Hell.

I get back to my Audit and move onto the notes that are kept on microfilm. The good thing about microfilm is that it’s strangely retro, the bad thing about it is that it takes forever and also that it gives me a headache.

You see we can’t keep the paper notes forever, so we send the old notes off site to someone who takes photographs of them and loads them onto films. Of course the private sector would scan them into a computer now. But no, we have the physical photos on a small film. There are several sets of notes on each reel and you have to flick through them all to find the one that you’re interested in.

I didn’t get what I wanted done. Which is annoying. So it will be in again tomorrow. Which is ok – I’m on nights, but I can never sleep the day before my first night anyway.

Whilst I was in the microfilm department I answered the bleep again and told the nurse (it wasn’t urgent this time) that it was my day off and could she get someone else. The Records clerk who was sitting next to me asked me why I was here on my day off.

‘Well because this isn’t work’ I replied.
‘It looks like work to me,’ She said

This got me thinking. Audits are important – they are the only way of measuring control in medicine, and it’s pretty difficult to go through medical records and pick out the saliant points if you aren’t a medic. And there just isn’t time to do an Audit in your working day. Research is good as well, it’s important to push medicine forward, and also to help you interpret the current data and be a proper scienctist. But that needs to be done in your own time as well, and then there’s exams. They need to paid for out of your own pocket (though there is some study budget for courses for them). They need to revised for in your own time as well.

Of course this is tricky for people who have a family, especially if the family doesn’t include a nice person to stay home and raise the kids whilst you go out to work. It’s difficult to find the time. If I had to finish at five to pick the kids up from nursery I’d probably never get anywhere with my career.

I don’t mind – I don’t have any kids. And if I wasn’t working in medicine I’d be a graduate trainee in some large company (hopefully). It’s well known that you get on as a graduate trainee by putting the hours in. I can’t see a trainee accountant in Andersons’ or whatever they are called now getting on by saying ‘it’s five I’m Leaving’. Mind you they get bigger bonuses than us. Though I have the compensation of not having to live in London and therefore being able to afford a nice house.

I have met several people who are older than average when they go to medical school, and by and large they don’t want to spend so much of there own time concatenating on there career as youngher people do..

Not that there’s anything wrong with just wanting a job and then going home, a lot of the advantage of general practice is that you don’t have to do research in your own time to ‘get on’.  Most older medics, those who did something else before medicine want a work life balance, and tend to stay away from traditional hospital medicine. Some of them told me that they were never told how difficult it was to combine career with family before they started medschool. In fact some medschools encourage older students because they have more experience, and tell them it’s a great career with work life balance and all. Yes you can train part time – but don’t forget it’s really difficult.

Which is why we should carry on recuriting the 18 year olds to medschool as well – because for certain things we need the long careers that come out of the other end. Older students do make a valuable contribution. My current houseplant is an excellent post grad medic, and very good, but he’s only in his 20s.

But I can’t imagine that those who will be in their 40s when they are junior doctors will want to spend another 15 years training to be consultants.

They’ll mostly want to be staff grades and GPs where they can have a life and settle down with their family, and this is all well and good, and to be commended. I know staff grades and GPs work hard, but there isn’t the constant push for promotion, the constant competition. You can just get on with seeing patients.

I know – all those good intentions to blog. But things are a bit hectic at the moment. There are several things that are making it difficult for me to blog at the moment. But the fact that I’ve been left messages by people who want to read the blog is encouraging me. So that’s a good thing.

  • A ward full of patients.
  • I know 48 hours a week is a pathetic compared to the old days. But the fact that I seem to spend all my spare time doing locums so I can pay the mortgage is rather time consuming. I like locums, I like the job, and I like the money. I really like the money. I still can’t believe how much they pay me! When I was a student I did lots of minimum wage jobs, and now when people offer me standard locum rates I say “yes. And there’s the fact that the general ward jobs are pretty darn time consuming.

  • PACES Evilness
  • I’m only 41 revision days from the the start of the next PACES period. It’s the clinical exam of the Royal College of Physicians and it’s terrifying. I failed my first attempt either because I’m rubbish or because it’s a hard exam. This time I’m feeling determined to pass. However all the nice registrars who were teaching me have moved onto new jobs, and I’m struggling to persuade consultants to teach me. I’ve resolved to do 1 hour of revision per day. It’s strange how difficult it is to fit in.

  • My Audit Hell
  • So I was doing this audit. You have to do Audits to get on in medicine you see. And I’d been going through notes and filling in questionnaires about how a certain condition was treated and investigated. And I had them in my bag. My bag which I left in the office on the ward. The office on the ward that, when I started, was locked with one of those code things. The office which the ward clerk had decided to turn into a place to store things, so had started propping open the door with the waste paper bin. And it hadn’t crossed my mind that this was the best place to leave my bag. I realised this when my bag went missing. With all my audit stuff in. Thank fuck it didn’t have any names on it or even identifiable information really. It was fairly standard information about a common condition. Other wise I’d be the next government data protection scandal.

  • Life
  • Yes, the usual sort of stuff. Life, 1 house, that needs cleaning occasionally, a collection of pets that need feeding and a girlfriend that needs attention. I’ve started to realise that if I want to waste an evening in an unproductive way then sitting at the computer is the best way to do it. So blogging’s been left by the wayside for a while.

It’s August. For me this means moving up to the dizzy heights of being a 3rd year SHO. Or ST2 as we’re now called in the brave new world that is MMC (*Spit*).

But a mere three years ago I was nervously anticipating the start of my new job, my very first proper job, my first job that paid more than a minimum wage.

Here’s what I wish I’d knew when I was a house officer – no, not all the stuff about medicine, you can pick up the does of Augmentin, though the most important thing is that you really have to have some evidence of infection before you give you elderly frail patient C Diff with it. But the other stuff. I’ve been lurking on ‘The Little Medic’s Blog’ and feeling all paternal, wanting to take him aside and give him hints and tips.

Dear Doctors starting work this August. This is my message to you. If you care that much…

  1. The only person who is impressed by your title is your  mother. I hate to take away the lovely feeling you get when you introduce yourself as Doctor. Being a Doctor does not come with respect, respect from other people, especially nurses, is something you will have to earn. Mainly by being nice and respectful and helpful.
  2. Your hours are not that bad really. You may feel tired: but you do less hours than your older colleagues, so whining about it won’t wash with anyone. 
  3. If you don’t know the answer to a problem find out. On his first day my current house officer asked me whether nurses knew he’d really just graduated – because he kept being asked questions that he didn’t know the answer to. But as a house officer you are the first point of contact to the medical team – if the nurses ask you to do something and you don’t know how – you learn. If the nurses just call the reg right away you won’t need anything.
  4. If you don’t know what to do and your patient is sick – call someone else. If you are out of your depth recognise it and ask for help. Think what you think you want need to do and make a start on it whilst you are waiting.
  5. ‘Routine jobs’ need a doctor to do them for a reason. Does it occur to you when you are prescribing fluids or prescribing warfarin or rewriting charts that you have the potiental to kill someone. Don’t be lulled into a fall sense of security.
  6. Do try and do your own cannulas – it’s lovely if nurses do them for you but really you will have to put them into sick people. One of the most stressful situations you will in is having a sick person you can’t get access to. (This in medic-languague is ‘failing to get access in a sickie’)
  7. Stay calm and don’t flap. It just makes life so much worse, though of course if you can’t get Iv access in a sickie, or are on your own with a sick person stress is an entirely appropriate response.
  8. Talk to relatives and patients and keep them updated. Relatives who are well imformed with the patients progress don’t become nightmare reliatives, it may be time consuming being around at visiting time – but it does mean people are informed and save hassle in the long term.
  9. Look your patients in the eye: and talk to them as well. See them as humans – see their problems, listen to them.
  10. Don’t stop learning. You never ever will – don’t get out of the habit of learning. I was preparing a presentation for a journal club the other week exactly the same thing I’ve been doing for years as a medical student.
  11. It’s actually really cool