Get to work, full box of files waiting. Nursing staff in a bad mood because no beds in the hospital and casualty acting as an 'overflow', 25 patients on trolleys taking up space. Mad, melodramatic overdose patient arguing loudly with everyone who walks past her that we are abusing her. Walk into resus: one patient on a ventilator (subarachnoid bleed), paeds busy resussing the crap out of a sick kid on the other side.
Go to 'minors' area. See 10 ankle injuries from previous weekend's drinking. 1 fracture. See 8 inappropriate GP referrals of abdo pain (...about 6 weeks doctor...). Convince the American tourist that she does not need an MRI scan to her head after she fell and sustained a 1cm laceration. Explain the term 'neurologically intact'. Explain that what happened to Natasha Richardson was terrible but that she will be OK. Counsel 2 anxious sets of parents that their child who bumped their head on the coffee table is not going to die, and give head injury instructions left right and centre. Panic quietly about the American tourist, find her in the waiting room and administer tetanus toxoid, previously forgotten.
Get called to resus to a 14 year old girl hit by a car. Pupils fixed and dilated. Abdomen hugely distended and blue, blood pouring out of left ear. Resus for all its worth and watch her slip away. Counsel her parents and see the empty desperation in their eyes and the way their lives collapse in front of me. Say a silent prayer that they will be OK.
Pull myself together, go back into minors, see the cutest kid in the world who gives me a hug after I glue his forehead laceration back together. Get a phonecall from the medical on call doc, who tells me that the STEMI patient I thromobolysed yesterday is doing much better, and said to say a special thank you to me. Reduce two dislocated shoulders. Place an elderly woman with dodgy heart and lungs on BIPAP and watch as she improves.
Leave an hour late. Run, cup of tea, blog. Think about the American again. Think about the 14 year old again. Feel extraordinarily grateful for everything I have.
Fall asleep, knowing that this job is just right... for me.
Friday, May 29, 2009
Monday, May 18, 2009
Back to school
The torture has begun. In my attempt to further my career, I will be writing an awful set of exams in August, the dreaded 'primaries'. I have decided to shock the old system and actually study a little bit more in advance than I did in my undergraduate years: and oh boy, its going tough. There is a huge amount of work.
Attention all medical students: some advice: PAY ATTENTION in physiology. No matter how hard or imcomprehensible it seems now, it will be much, much worse in 5 or 6 or 7 years time. Take it from me.
Attention all medical students: some advice: PAY ATTENTION in physiology. No matter how hard or imcomprehensible it seems now, it will be much, much worse in 5 or 6 or 7 years time. Take it from me.
The Drunkest Girl in the World
She was 15. She was a mess: eyeliner smeared down her face, hair matted against her forehead, blood pouring out of her scalp wound and pooling neatly around her right ear. Her bright yellow tank top was pulled up to underneath her breasts, revealing a young, soft, round tummy bulging over her 'skinny' jeans. She had several piercings in each ear, and ones on the right were covered in blood, and dripping delicately over everything. She had positioned herself on a chair, propped herself up in the corner, and fallen asleep. She reeked of a lovely combination of cheap 'Charlie' perfume and cheaper 'papsak' wine.
I set up my suture tray, shook her awake and removed the blood soaked bandage. There was a 5 cm scalp laceration that needed cleaning and suturing. However, this is difficult if your patient keeps falling over onto your lap. I tried again and again to wake her up, unsuccessfully. Her boyfriend was at the window, shouting abuse at the casualty staff (he may well have been the Drunkest Man in the World.)
I got one of the nursing staff to hold up while I quickly fixed her up. I didnt even consider using lignocaine, and she didnt notice. After I had stapled her scalp, we got up to get a bandage to cover up her wound, and she slowly slid off the chair. She seemed completely paralysed, with no control over her limbs. She slumped between the chair and my trolley, against the wall. Slowly a puddle began to form under her. We noticed the darkening of her jeans. She had lost control of her bladder and was now lying in a pool of her own bodily fluids, blood and fresh alcohol laced urine. She didnt move a muscle, just continued to pee; it seemed like LITRES of urine. By now all the other patients and staff were staring. Even the boyfriend had shut up.
You can fix people's wounds but you cant always give them their dignity back.
I set up my suture tray, shook her awake and removed the blood soaked bandage. There was a 5 cm scalp laceration that needed cleaning and suturing. However, this is difficult if your patient keeps falling over onto your lap. I tried again and again to wake her up, unsuccessfully. Her boyfriend was at the window, shouting abuse at the casualty staff (he may well have been the Drunkest Man in the World.)
I got one of the nursing staff to hold up while I quickly fixed her up. I didnt even consider using lignocaine, and she didnt notice. After I had stapled her scalp, we got up to get a bandage to cover up her wound, and she slowly slid off the chair. She seemed completely paralysed, with no control over her limbs. She slumped between the chair and my trolley, against the wall. Slowly a puddle began to form under her. We noticed the darkening of her jeans. She had lost control of her bladder and was now lying in a pool of her own bodily fluids, blood and fresh alcohol laced urine. She didnt move a muscle, just continued to pee; it seemed like LITRES of urine. By now all the other patients and staff were staring. Even the boyfriend had shut up.
You can fix people's wounds but you cant always give them their dignity back.
ATTENTION PLEASE
To all the admitting teams I refer to:
I would like to being the following to your attention:
1)We are here to work. YOU are here to work. You are getting paid overtime to be here late at night, and while I appreciate that it is crap, you being snotty to me on the phone at 3 am will NOT help matters. I have been there, I have also done the 36 hours without any sleep, and I know it is bad. I am not waking you up/referring another patient to be funny, I am doing so because they are sick and need admission.
2) Just because A and E officers work 8 or 12 hour shifts does not mean we are lazy. While you deal with pretty much the same, day in and out (with the occasional 'pink canary'), we have to deal with everything and anything that gets thrown our way. Because of overcrowding and a lack of beds, we have to deal with uppity, angry people ALL THE TIME, because they have been waiting 8 hours to be seen. We are at the proverbial front line of people's emotions, all the time. We soften them up for you. We explain whats going to happen, we console. We also provide life saving interventions all day, and do resus after resus after resus. Its very emotionally and mentally draining. We work just as hard as you.
3) If you go to theatre for any period of time and you are on call for casualty, you need to get someone to cover for you. Or at least answer your bleep. End of story.
4) Please trust me. Again, I am not referring patients for a 'second opinion', or because I am trying to be mean. I am doing so because I believe that they have a condition which prevents discharge. This opinion is formed from a)the history I have taken from the patient, b) the examination I have performed and c) the investigations I have done. There is always a reason.
5) If I tell you that a patient is unstable, this is not to try and place undue pressure on you or annoy you. I know you have five patients waiting to be seen. But you need to prioritise. I am only telling you the patient is unstable so we can try get them to theatre/CT scan/ICU a little bit quicker. I will do my best to stabilise and manage the patient as I can, but most will need further intervention.
6) We have protocols in place for a lot of conditions: we use them. Please do not argue with me about a referral if I have followed a protocol/guideline and you are the end point.
And while we are at it:
To the doctors I have referred patients telephonically to while sitting at a peripheral hospital, terrified and desperate:
a)Yes, I might be more junior than you, but I am not stupid. Please do not treat me as such. I know you are stressed, so am I! If there is something missing from what I am telling you, or something you want me to do tell me exactly what it is, and let me phone you back. I am phoning for your help. Please give it.
b) It is easy to forget what it is like to work in a hospital that has no CT scan, no after hours blood laboratory, no after hours Xray, insufficient or undertrained staff and no consultant support. That is where I am. Picture it for a minute and then please give appropriate advice. Thank you.
And that said:
To all the doctors in Ireland and South Africa who have been friendly, kind, helpful and supportive, THANK YOU. Know that A and E has got your back.
I would like to being the following to your attention:
1)We are here to work. YOU are here to work. You are getting paid overtime to be here late at night, and while I appreciate that it is crap, you being snotty to me on the phone at 3 am will NOT help matters. I have been there, I have also done the 36 hours without any sleep, and I know it is bad. I am not waking you up/referring another patient to be funny, I am doing so because they are sick and need admission.
2) Just because A and E officers work 8 or 12 hour shifts does not mean we are lazy. While you deal with pretty much the same, day in and out (with the occasional 'pink canary'), we have to deal with everything and anything that gets thrown our way. Because of overcrowding and a lack of beds, we have to deal with uppity, angry people ALL THE TIME, because they have been waiting 8 hours to be seen. We are at the proverbial front line of people's emotions, all the time. We soften them up for you. We explain whats going to happen, we console. We also provide life saving interventions all day, and do resus after resus after resus. Its very emotionally and mentally draining. We work just as hard as you.
3) If you go to theatre for any period of time and you are on call for casualty, you need to get someone to cover for you. Or at least answer your bleep. End of story.
4) Please trust me. Again, I am not referring patients for a 'second opinion', or because I am trying to be mean. I am doing so because I believe that they have a condition which prevents discharge. This opinion is formed from a)the history I have taken from the patient, b) the examination I have performed and c) the investigations I have done. There is always a reason.
5) If I tell you that a patient is unstable, this is not to try and place undue pressure on you or annoy you. I know you have five patients waiting to be seen. But you need to prioritise. I am only telling you the patient is unstable so we can try get them to theatre/CT scan/ICU a little bit quicker. I will do my best to stabilise and manage the patient as I can, but most will need further intervention.
6) We have protocols in place for a lot of conditions: we use them. Please do not argue with me about a referral if I have followed a protocol/guideline and you are the end point.
And while we are at it:
To the doctors I have referred patients telephonically to while sitting at a peripheral hospital, terrified and desperate:
a)Yes, I might be more junior than you, but I am not stupid. Please do not treat me as such. I know you are stressed, so am I! If there is something missing from what I am telling you, or something you want me to do tell me exactly what it is, and let me phone you back. I am phoning for your help. Please give it.
b) It is easy to forget what it is like to work in a hospital that has no CT scan, no after hours blood laboratory, no after hours Xray, insufficient or undertrained staff and no consultant support. That is where I am. Picture it for a minute and then please give appropriate advice. Thank you.
And that said:
To all the doctors in Ireland and South Africa who have been friendly, kind, helpful and supportive, THANK YOU. Know that A and E has got your back.
Back in the game
I suppose its not the best idea to start a new blog, post a couple of posts... and then disappear for three weeks. So I am sorry budding fan club, we are back! Was on a brief holiday home to South Africa. And yes, thank you for asking, it was FABULOUS. Got to see my good friends Karen and the Adman, and lots of other awesome guys and gals. I cannot wait to get back for good... yes its true folks, I am going Home, and will be starting an amazing job in the Cape in July. But never fear, this blog will continue... I have a feeling there's no cure for stupidity in South Africa either.
Wednesday, April 22, 2009
Old people
In the state system in South Africa, we didnt see old people. Not REALLY old people. The combination of HIV/AIDS, poorly controlled diabetes and hypertension and trauma meant that sadly, if you made it to 75, you were lucky.
In Ireland, we have the flip side of the coin.(I am sure this is true of most '1st world countries'). People get Old here. Really old! I did 6 months of medicine last year, and it was a massive crash course in geriatrics. I had no idea of the intracacies of taking a history from an aged person, or which are the right questions to ask, or how to ask them, or what differential diagnoses you need to consider. It was a steep learning curve, but I got there in the end, and now feel pretty confident with the oldies.
I have mixed feelings about the aged population: they can be VERY difficult to deal with, and sometimes their families are even worse. So here are a couple of thoughts about old people...
1)Their bowel movements are REALLY important to them. I once (accidentally!!) made an old lady cry when I told her I needed to put on a backslab for her elbow fracture: she wasnt upset by the fracture or the backslab, but the fact that she needed to have a bowel motion at 8 am every day, and wouldnt be able to successfully do so with backslab in situ.
2)Their families can be their best allies... or their worst enemies. People who care for the aged fall into two categories: excellent or appalling. The former are supportive, visit their old person regularly, dont mind helping change dressings or adult nappies, provide practical help with food and walking aids etc, and are generally well informed about the medical conditions, medications and are willing to practical and realistic when the time comes to make big decisions, eg resus decisions.
The latter are the opposite: they are overly 'possesive' of their old person, but without any thought to how to really help: I have seen old men who live with their daughters coming in with weeks worth of dirt caked in their fingernails, dirty greasy hair, and toenails creeping under the bottom of their toes- could you not run your dad a bath? could you not help him clip his toenails? With his arthritic back and hips he probably cant manage to do these things on his own anymore.
When you suggest to this type of person that the old person needs to go home with a catheter/have dressings changed daily/have someone supervise medication, they will argue loudly with you and explain why they cant possibly do this, even though they are the 'carer' (and sometimes, getting the state 'carer's allowance!).
3) They are NOT stupid, but people treat them like they are. For the first time in my life, I encountered patients here who have never been told their diagnosis, even when its something like cancer!, because their family 'thought it best' not to tell them. What a load of hooey.
4) Loneliness is what kills most old people. (Apart from strokes and MI's obviously!). My heart breaks for these old ladies who have outlived their husbands by 30 years, or old chaps who live on their farm with their equally old brother, unable to farm anymore, but without anyone to sell or give the farm to. There is a big problem of alcohol abuse in the elderly here, but I understand it to an extent: They go off to the pub every day and have lunch there, both for the food and the company, and end up with a life long habit of 2 or 3 pints a day.
I'm not a big fan of oldies, and those who know me will know that I am not the most patient or people: but in dealing with the elderly I have learnt a bit of compassion, and also what it means to really be the patient's advocate: someone needs to stand up for them! Then again, maybe I'm just getting older myself, and a bit soft in the head:)
In Ireland, we have the flip side of the coin.(I am sure this is true of most '1st world countries'). People get Old here. Really old! I did 6 months of medicine last year, and it was a massive crash course in geriatrics. I had no idea of the intracacies of taking a history from an aged person, or which are the right questions to ask, or how to ask them, or what differential diagnoses you need to consider. It was a steep learning curve, but I got there in the end, and now feel pretty confident with the oldies.
I have mixed feelings about the aged population: they can be VERY difficult to deal with, and sometimes their families are even worse. So here are a couple of thoughts about old people...
1)Their bowel movements are REALLY important to them. I once (accidentally!!) made an old lady cry when I told her I needed to put on a backslab for her elbow fracture: she wasnt upset by the fracture or the backslab, but the fact that she needed to have a bowel motion at 8 am every day, and wouldnt be able to successfully do so with backslab in situ.
2)Their families can be their best allies... or their worst enemies. People who care for the aged fall into two categories: excellent or appalling. The former are supportive, visit their old person regularly, dont mind helping change dressings or adult nappies, provide practical help with food and walking aids etc, and are generally well informed about the medical conditions, medications and are willing to practical and realistic when the time comes to make big decisions, eg resus decisions.
The latter are the opposite: they are overly 'possesive' of their old person, but without any thought to how to really help: I have seen old men who live with their daughters coming in with weeks worth of dirt caked in their fingernails, dirty greasy hair, and toenails creeping under the bottom of their toes- could you not run your dad a bath? could you not help him clip his toenails? With his arthritic back and hips he probably cant manage to do these things on his own anymore.
When you suggest to this type of person that the old person needs to go home with a catheter/have dressings changed daily/have someone supervise medication, they will argue loudly with you and explain why they cant possibly do this, even though they are the 'carer' (and sometimes, getting the state 'carer's allowance!).
3) They are NOT stupid, but people treat them like they are. For the first time in my life, I encountered patients here who have never been told their diagnosis, even when its something like cancer!, because their family 'thought it best' not to tell them. What a load of hooey.
4) Loneliness is what kills most old people. (Apart from strokes and MI's obviously!). My heart breaks for these old ladies who have outlived their husbands by 30 years, or old chaps who live on their farm with their equally old brother, unable to farm anymore, but without anyone to sell or give the farm to. There is a big problem of alcohol abuse in the elderly here, but I understand it to an extent: They go off to the pub every day and have lunch there, both for the food and the company, and end up with a life long habit of 2 or 3 pints a day.
I'm not a big fan of oldies, and those who know me will know that I am not the most patient or people: but in dealing with the elderly I have learnt a bit of compassion, and also what it means to really be the patient's advocate: someone needs to stand up for them! Then again, maybe I'm just getting older myself, and a bit soft in the head:)
Nights
Midnight to 8 am is a funny shift: it sounds awful, but is actually pretty great. I dont mind nights at all: you get to miss most of the bullshit that parades through casualty in the day, and actually help (mostly) sick people, and you get to take guilt free naps all day. It gives me a secret thrill when I get into bed at 09h30, knowing that most people are just starting their working day.
Doing a week of nights does warp your perspective of time a bit: usually I'm not sure what the date or day is, someone has to tell me at the start of every shift. I am a great procrastinator, and this gets worse on nights, where, before you realise it, its the end of the week and you have done NOTHING productive except work and take numerous naps in the day. My running program takes a pause during my weeks of nights, and sadly, I end up eating the same thing 5 or 6 nights in a row (usually make a big dish of lasagne or whatever... ).
I quite like the vibe at 4 am: casualty never sleeps, there is always something happening....I always wonder about people who come in to hospital in the early hours of the morning: obviously if you wake with crushing chest pain, thats one thing, but people who come in with say, a recently twisted ankle, at 5 am. What were you doing to twist your ankle at 4 am? Why weren't you SLEEPING?Anyway, I dont really mind, it keeps things interesting.
The only other down side of nights is that it really buggers up your sleep pattern for a couple of days.... I usually cant get to sleep for at least 2 or 3 nights after nights... its quite frustrating!
Last night was a good night: wrestled with a man's shoulder until it popped back with a satisfying clunk, helped 3 MVA victims (they were all fine), listened to numerous old grannies and their dodgy hearts and lungs, reassured patients and their families, referred on all my patients without any arguments with the admitting teams (I'll write another post about this another time...), and still had time for coffee and a hot cross bun at 4 am. Sometimes I REALLY love my job:)
Doing a week of nights does warp your perspective of time a bit: usually I'm not sure what the date or day is, someone has to tell me at the start of every shift. I am a great procrastinator, and this gets worse on nights, where, before you realise it, its the end of the week and you have done NOTHING productive except work and take numerous naps in the day. My running program takes a pause during my weeks of nights, and sadly, I end up eating the same thing 5 or 6 nights in a row (usually make a big dish of lasagne or whatever... ).
I quite like the vibe at 4 am: casualty never sleeps, there is always something happening....I always wonder about people who come in to hospital in the early hours of the morning: obviously if you wake with crushing chest pain, thats one thing, but people who come in with say, a recently twisted ankle, at 5 am. What were you doing to twist your ankle at 4 am? Why weren't you SLEEPING?Anyway, I dont really mind, it keeps things interesting.
The only other down side of nights is that it really buggers up your sleep pattern for a couple of days.... I usually cant get to sleep for at least 2 or 3 nights after nights... its quite frustrating!
Last night was a good night: wrestled with a man's shoulder until it popped back with a satisfying clunk, helped 3 MVA victims (they were all fine), listened to numerous old grannies and their dodgy hearts and lungs, reassured patients and their families, referred on all my patients without any arguments with the admitting teams (I'll write another post about this another time...), and still had time for coffee and a hot cross bun at 4 am. Sometimes I REALLY love my job:)
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