30 days

i've decided to sign myself up to this 30 days project. this is all in an attempt to update this blog a bit more than "occasionally".

whether i succeed is another matter.

please join too fellow bloggers! prove to yourself that you are not professional procrastinators!

[i am listening to the zutons]

take your performance feedback and shove it up...

... because my good friend in wales and i have both passed our exams (membership of the royal college of physicians 2: die harder).

i was foolish enough to NOT opt for getting my marks published on the web so i had to wait till today for the stupid envelope.

anyway it is a massive relief for us both (failures the first time round) and so we are kicking back and relaxing this weekend. he is paintballing for a stag weekend and i am going bowling tonight lebowski style.

i nearly stayed in again last night but managed to pull myself off the sofa to go for a few beers with an old friend. it is tragic. i can't drink as much as i used to by any stretch of the imagination and i was almost content to veg on the sofa overnight.

but i pulled myself up and moseyed on out (well just locally) as i think if i become the sort of person who works, eats and sleeps that will be a non-existence.

i have a couple of incidents at work to report to you all. but i shall leave that for the next post as i am too excited and relieved at the moment.

sometimes you hit the bar and sometimes the bar hits you

[i am listening to Romeo and Juliet by Dire Straits]

you're a lightweight. you're fired.

dr D&C was skiving on friday.

that's not strictly true. i'm going to be unemployed in august and so i said to the house officers that i would be in at 9.30am because i wanted to hand in a job application at another hospital. i also said to them bleep me if there are any problem because yes ladies and gentlemen my pager not only works in the hospital, it also works at home, it works at my friends' houses, it probably works abroad and when i have left this corporeal existence and ascended to a higher plane of consciousness/the afterlife, i am sure that it'll still be putting through the crash calls at 3am.

anyway i left my friend the bleep/pager switched on and sure enough at about 9.15am it went off. i called the phone number displayed and to my suprise it was the voice of the clinical director that answered.

being called by the clinical director is a rarity. it is also quite frightening. you feel a bit like the generals in that scene on the death star in Star Wars when darth vader announces that the emperor will shortly be arriving. "the emperor is coming here?" reply the assembled generals, terrified faces, poop in their pants.

actually our leader is quite a nice guy. he tutored me as a student and i quite liked him. what on earth could he want though? i briefly scanned my mind of the medical activities i'd been involved in over the past few months. no, i couldn't think of any obvious malpractice.

he asked me if i had a minute. i was buying a coffee so i guess i did. he proceeded to ask me of my thoughts on a radical shake up of the way the hospital works. yes he was asking me about hospital at night.

i won't go into HaN in detail as i have ranted at length about it here. also refer to Dr Crippen for more details. in short the idea is that you only need a skeleton crew to run a hospital overnight and at the moment there are too many doctors doing far too little work.

the wonderful thing about HaN is that it is marketed (in the labour spin world) as something to help us doctors have a smoother time on call. bollocks i say! it is about cost cutting and meeting working time targets. that is what it's about.

at present in my hospital we have two junior doctors covering the wards, splitting the hospital geographically down the middle. what the clinical director was asking was why not get rid of one of the doctors and provide an advanced nurse practitioner with advanced skills (he said advanced twice) instead.

what are advanced skills? i'm not sure really.

bow hunting skills? computer hacking skills?

anyway i said i'd let him know on monday because delight of delights i was to be night shifting across the weekend. and off i scampered into work that night.

the weekend was fine as it happens. people weren't very sick and the stuff i had to do was quite basic... for me. initially i thought about writing back to mr clinical director with "bring on the nurse practitioners and screw you guys i'm going home."

but then in retrospect i thought about the activities i'd got up to overnight. for example prescribing fluids. this is relatively easy but then after three years of medicine i can very quickly assess someone's hydration status, their requirements, factor in their cardiac/renal status, correlate this with their electrolyte results and give them the right fluid at the right speed so that their organs get adequate perfusion and they don't drown in fluid. though it has taken me a long time to get to that level.

so i am a little perturbed at a nurse practitioner rocking up and ploughing 3 litres of gelofusin into a tiny man whose heart has the equivalent pumping function of a small clementine. that could be a disaster.

similarly i had lots of people with chest pain. again you have to worry about the heart. even if you take a careful history and look for (what can be subtle) changes on the ECG it can be a very difficult call. do we want nurse practitioners with no cardiac training to be doing this? i'm not sure (though having said that the CCU nurses i worked with were superb.)

anyway i sent my email back to the big boss saying that i didn't think that we were ready for this scheme. if the nurses had years of medical training and experience (ie were doctors) it would be fine. knowing my hospital they'd do it on the cheap and employ someone who was all talk and no ability.

did he reply? yes he did.

"thanks for the email. take care."

who says i don't make a difference?

[i am listening to the specials]

Escapism

a quarter of my patients have cancer of some kind.

i've spent the last few days taking them into quiet rooms, sitting them down, asking the same question over and over.

"what have you been told so far?"

they go on about how they came in with a chest infection/fluid on their lungs/etc and then i have to launch into the splendid bullshit.

"that's right. now that scan we did yesterday. well it's shown a lesion/mass/abnormality/cyst/shadow/irregular feature and we need to do a few more tests and speak to a few specialists before we can tell you exactly what it is and act accordingly."

what i want to say is that it looks, smells and tastes like cancer. you have cancer. and the pains we'll put you through to get the sample of tissue to prove this isn't going to change the fact that you have cancer.

of course we're not supposed to say that. in fact i got a telling off as a freshly qualified boy doctor for saying to a patient that although we weren't sure yet what we were concerned about was the possibility that his mass (in his pancreas) may be cancerous.

bad Dr D&C. go and kneel before the GMC with your trousers down.

don't you realise, i was told, that if you even MENTION the "C-word" then it will do more damage than the diagnosis itself.

quoi?

the word will do more damage than the cancer? somehow the word will metastasise and infiltrate all his organs? the word will cause him unbelievable pain and nausea and diabetes in a cruel twist?

no, i was told, we must wait for a tissue diagnosis.

of course said tissue sample took four weeks to get because the procedures (cameras down his to his duodenum and the probing around with a brush in various sphincter) ran into problems each time. anyway, we did finally get the biopsy, we told him he had cancer, he said he had expected that it was going to be cancer and then he died the next day.

but of course it was not the adenocarcinoma that killed him, it was the word.

anyway i must now bite my tongue. i shall wait the time it takes to get Mr K's pleural fluid back from cytology, i shall sit in patience as the lab slices through Mrs G's gastric biopsy and i shall make sure everything is ok after they've had a wash around Mr P's lungs with the bronchoscope. and then, one week on, EVEN THOUGH WE ALL KNOW NOW THESE PEOPLE HAVE CANCER, we shall tell them that they have cancer. in the meantime i shall lie every day to them, through the veil of " we need to do further tests" and "the lab is still processing the sample you poor cancer riddled bastard" before calling in the palliative care team who can start the syringe full of morphine and hasten their discharge to Rose Cottage.

excuse me, i have to go and put on my best used car dealer outfit in preparation for a day full of mendacity.

[i am listening to Primal Scream's new single. i saw this on the web today and it made me very geekily excited]