So that I may remember why all things were created
Tuesday, February 28, 2006
Grand Rounds Vol II, No 23
So this is the first time I've participated in the medical bloggers' Grand Rounds at Bard Parker's website.
The medical grand rounds are a weekly event in any doctor's life - it's where we come together and talk about interesting cases that we have seen on the wards or the latest developments in research or the latest guidelines for patient management.
The theory behind it is that the doctors from different specialities and from different stages of training can learn from each other and exchange opinions.
The reality is that it is an opportunity for junior doctors to show off their presentation (read: Powerpoint) skills and allow the senior doctors a chance to heckle them.
Day 6 (today): We have just purchased a new fish for the biOrb! Hooray! Our new addition is a Betta splendens, otherwise known as the Siamese fighting fish. He is absolutely beautiful - covered in red scales fringed with purple and blue, with long flowing red fins.
It was breaktime and a few of the nurses were sitting in the staff room with me, each of us clutching a warm mug of tea and poring over some outdated gossip magazines.
The door slammed as two of the senior nurses walked in, discussing two patients that had been transferred to the elderly care unit. One of them had Alzheimer's disease, and the other had Parkinson's disease. They were both equally unwell with pneumonia.
"Which would you rather have - Alzheimer's or Parkinson's?", said one.
"Neither!", said the other, and we all laughed. Slowly, our eyes began to glaze over, as we all stared off into empty space, pondering. Which would we rather have?
I would prefer to enter the slow and grey decline of Alzheimer's disease. As my mental processes begin to deteriorate, and I become less aware of my surroundings, hopefully I would approach a state of pleasant confusion. I would be unconscious of the suffering of the people around me, as I become more child-like and less capable of looking after myself. I would be oblivious to the weakening of my body. I would forget where I was, who I had been, what I had done. The days and nights drifting together, I would live in a state of tranquil ignorance.
Rather that, than to have my mind intact whilst my person fails. And to know what lies in store.
"I'm not goin' yet. Don't you worry, I'm not goin' yet."
His voice whistled through the air, thin and wispy through the clamour of the resuscitation room. A shimmer of sweat covered his face and he grasped my hand as I offered him the oxygen mask, and he looked at me with watery eyes, the blue of his eyes so pale it was almost silver.
"I'm still waiting."
I looked again at the large wounds on his legs, blood trickling through the mounds of gauze, the splintered ends of bones protruding through paper-thin skin, gleaming yellow in the light. He was too weak to survive an operation to repair his legs...and he did not want one.
He had lain on the floor too long after falling from a ladder. His neighbours, elderly like himself, were too deaf to hear his weak cries for help. His lungs filled up with fluid that he could not cough up. His blood soaked had through the carpet. He had waited until somebody noted his absence from the Sunday church service, the empty pew in the corner near the stained glass window with the image of Mary.
The morphine was bringing him very little relief, but he did not want any more.
"I want my mind to be clear for when the priest comes. I won't go until I've had my last rites."
He grasped at his blanket, twisting it in his bruised hands, the nails yellowed from years of nicotine use, the skin crisscrossed with white scars, the fingers bent and warped. His eyes were closed and his breathing became slower, fainter, slower still, fainter still.
And we waited.
The priest finally arrived in his dark robes and holding a small vial of holy water. His voice was deep and he when he spoke it was like a song, a lullaby that rose and fell, a haunting sound that felt alien in this land of green monitors and tinny machinic blips.
As the song ended, the old man opened his silver eyes, looked around at us all and then sat up, smiling.
Then the breath left his lips like smoke blowing away in the wind, and the light faded slowly from his eyes.
8:30am - Breakfast for me, and then I'm checking out the careers websites on the internet to look for job openings.
11:24am - I've completed 3 application forms and am printing them out. Meanwhile, I watch the neon tetras darting about the biOrb. One of them looks significantly more swollen than the others. Maybe it's sick! Panicked, I search the online aquarium forums for information and then stare obsessively at the fish, looking for signs of disease.
12:11pm - I think the fish is alright. Maybe it is just fat. I'm so glad I'm not a vet.
12:35pm - I'm eating lunch whilst studying. I have my textbook in front of me, and the revision website open on my computer. I've got to cover one topic a week in preparation for the post-graduate part 1 exams.
1:40pm - The boiler mechanic arrives. He's come to replace some random parts of the boiler that have worn out. He spouts technical jargon at me whilst the boiler makes clanking noises when he fiddles with dials and switches. Finally, he is done. Now I can have hot showers! Hooray!
2:30pm - I throw my coat on for a jaunt downtown. Halfway there, I realise that I've forgotten to bring some cheques that I meant to pay in. I drop off some parcels at the post office, post the completed application forms and buy some stamps. I stop by Boots the Chemist and get some moisturising cream (Garnier Body Cocoon), plain aqueous cream and Palmolive 'anti-stress' body wash. My skin has been very dry lately in this winter weather. One of the other customers recognises me and asks me for my recommendation in skin creams. I tell her to get the aqueous cream - £2, hypoallergenic, comes in a 500ml tub, lasts at least 6 months if you use it all over twice a day.
4:15pm - Back at home, I finish another application form that needed to be handwritten (grumble). I hate it when you can download forms from the internet, but they've been made into .pdf format which means writing the same old thing which I could have just cut and paste from another form.
5:15pm - MDH texts me and sheepishly informs me that he will be running late this evening. Pah. I realise that I can't find the meat that I'd left out to defrost - MDH has cunningly put it in the fridge. Aargh. It is still solid ice in the centre. This ruins all my plans for dinner. I decide to order in pizza instead. If I can find the leaflet aound here somewhere...
6:20pm - Pizza is on the way! I feed the fish and watch them scrabble madly around the bowl. What is that...? Argh! There are some tiny white worms swimming in the water. Are they flukes? Maybe that's why one of my fish has gotten so fat! They're worm-infested! Panicked, I search the online aquarium forums for information and then stare obsessively at the fish, looking for signs of disease.
7:00pm - My fish are fine. The worms are called 'Planaria' and they are harmless towards fish. I resolve not to feed my fish for a few days so as to avoid an infestation. I am so glad I'm not a vet.
8:10pm - Pizza is here, MDH is here. MDH is bugging me to get off the computer and watch '24' with him. Bye.
Why the doctor doesn't appear to care when you come in with...
Back Pain
1. You walk in on your own with no apparent difficulty. Contrary to popular belief, doctors can tell when a patient is putting on a big display for our benefit. Thank you for your kind efforts, but we're not going to be fooled. You can stop limping now.
2. You are all hunched up in the bed/in the chair, moaning. People with back pain tend to keep their backs stiff and straight - even then, I still may not care. Your posture is terrible, by the way. Take some deportment classes.
3. You wrenched your back in a rugby scrum last week and today decided to help a friend carry his piano up the stairs. You are a very kind person, but also very stupid. No more heavy lifting for you. This also means no lifting shopping bags/carrying children/doing handstands/moving crates.
4. The nurse offered you pain relief but you politely declined. You martyr. Get outta here.
5. It happened after sleeping rough on somebody else's floor following a night of particularly intense carousing. Go have your hangover at home in your own bed.
6. You haven't changed your mattress in 15 years - the bed sags in the middle. 'Nuff said.
7. It happened after a visit to the chiropractor/osteopath. You should go and get your money back.
8. Your back pain miraculously recovers when I explain that a digital rectal examination is necessary in order to test the nervous supply of the anal sphincters.
9. You hurl abuse at the nurses when they refuse to give you morphine for your pain. You apologise to them first, then maybe I'll give a care.
10. Your pain is down your entire back. Everything hurts! What do you want? A new spine?
Why the doctor doesn't appear care when you come in the A&E with...
Abdominal Pains
Because:
1. Despite your pain, you were still able to play football and then go on a pub crawl with your friends and drink yourself into a giggling stupor. Go have your hangover at a friend's place.
2. You are thrashing around on your trolley and screaming. People with really serious abdominal pains lie rigid and still.
3. You have had several episodes of diarrhoea and vomiting after eating some half-cooked kebabs that you found at the back of the fridge. Ugh.
4. You refuse pain relief. What a stoic. Why don't you just stay at home, then?
5. You smoked a few marijuana joints this afternoon. Get lost, you junkie.
6. You don't appear to notice the pain when we're talking to you whilst feeling your abdomen. Get a clue, Drama mama.
7. You've consulted Dr MSN and Dr Google and you're utterly convinced you have a rare condition that Dr Obscura wrote about in his 1633 case report.
8. You're constipated because you never eat vegetables. Buy some Fybogel, then.
9. Your acupuncture nurse advised you to come to hospital because he's decided that you are deficient in selenium. Maybe your acupuncture nurse should treat your selenium deficiency himself.
10. You've just had a dinner consisting of 1 grilled steak, 3 chicken pies, 2 jacket potatoes topped with cheese and baked beans, 1 chocolate torte, half a swiss roll and 5, maybe 6 pints of lager. The pains started when you tucked into your second helping of trifle. Well, that'll learn you.
How horrible it must be to put your 5 month old baby boy to sleep and then check on him an hour later, to find him lying quiet, cold and still.
How horrible it must be to call the ambulance whilst cradling a silent, pale baby in your arms and then wait a few minutes - an eternity - for them to arrive.
How horrible it must be to watch 5 doctors and 6 nurses descend upon you in the hospital, snatch your child away, and then try to force life back into his tiny little body.
How horrible it must be to stand in the corridor, waiting, waiting while people hurry past you and avoid your gaze, knowing deep in your heart that your baby is already gone.
How horrible it must be to return home to a quiet house and have to face the nursery with an empty cot, now a crime scene swarming with police.
So we carefully and lovingly aquascaped and set up our fishtank, and then let it run for about ten days to let the water mature.
Fishless cycling, a technique for preparing and establishing an aquarium, is in vogue at the moment, as MDH and I have discovered. It is supposed to be more humane than introducing cheap and hardy 'suicide fish' - little brave pioneers that are sacrificed in order to make ready the territory for future generations.
So MDH and I have been staring at a lovely plant-filled, but fish-free tank for the last ten days.
It's been very relaxing, watching the bubbles and listening to the quiet hum of the filter but I could hardly wait to introduce some piscine creatures into the Orb.
Today, there six sparkly little Neon Tetras that are happily exploring their new home. A Valentine's Day present from MDH.
Here they are, dithering behind the resident Java Fern.
Aren't they lovely? I can't wait until I can add some other fish into the tank and create a little community. Anybody have any ideas on what fish would be good in a small 30litre tank?
One of these things is not like the others, One of these things just doesn't belong, Can you tell which thing is not like the others By the time I finish my song?
So here's a list of objects - guess which one does not belong and why: 1. Paper 2. Razorblades 3. Television antennae 4. Umbrella 5. Pencils 6. Doorhandle 7. Shards of glass 8. Paperclip 9. Wooden spoon 10. Tampon 11. Eggs 12. Coat hanger 13. Remote control 14. Mobile phone 15. Hairbrush
Did you guess which thing was not like the others? Did you guess which thing just doesn't belong? If you guessed this one is not like the others, Then you're absolutely...right!
1. It is not boring. There is always something for me to do. If I'm not seeing a patient, I'm writing up notes or dictating letters or teaching a medical student or discussing a case with the nurses or other doctors. I'm not always doing the same thing, because every patient I see is different from the last.
2. I'm always using my mind. I'm always thinking, observing, learning. My brain does not gather dust.
3. Meeting people. Growing up in Singapore has made me a sheltered person. In the hospital environment, I learn to deal with people from different backgrounds to myself. It makes me more aware about what happens in the world and what sort of needs different people have.
4. Being in a position to make an impact. I want my patients to believe that there are people in this world who really care about individuals, that doctors are people whom they can trust and who are really trying to help. Very occasionally, I get a look or a smile from someone...and I know I've made a difference to them.
5. I get a kick out of the other medical staff. Healthcare professionals are some of the most bizarre, neurotic crackpots you'll ever meet. We are downright insane. It's the combination fo caffiene and adrenaline that makes us this way. I love listening to the nurses bitch about the occupational therapists who bitch about the physiotherapists who bitch about the social workers who bitch about the doctors who bitch about nurses. But yet we all get along because it's a beautiful circle of hilarity. During a quiet spell last week, the porters found this giant stuffed bunny, wrapped a bandage round its head and put it in an empty hospital trolley in our resus room and called out a 'code blue'. This was incredibly entertaining for everybody.
6. Money is not a problem for me. This is mostly because I don't often have time to spend anything that I earn. Plus I save money on bills because I'm never at home, and I save on food because I hardly eat etc.
7. Weight is not a problem for me. Last year, I calculated that I walk an average of 15 km a day just walking back and forth between wards. Additionally, like many of my predecessors, I have developed a "carrot-and-stick" speedwalking technique which allows us to move three times as fast as a normal person (carrot = leaving work on time, stick = getting yelled at by 4 different senior doctors and 15 staff nurses). Eat my dust.
8. My opinion matters to people. The minute I started my clinical years at medical school, people have been asking me questions. I can give out medical advice to my friends and family. I can decode 'medispeak'. It saves them a lengthy trip to the hospital at times. I also find myself discussing contraceptive options with brides-to-be and nappy rash creams with mothers-to-be. It's nice to be used as a resource.
9. I have never appreciated the small things in life more. Sleeping in a bed. Taking a hot shower. Eating a warm meal with utensils. Drinking water from a glass. Sitting on the sofa with my husband. Walking in the sunlight. Grocery shopping. Man, I loooove grocery shopping.
10. I get to wear pajamas and trainers to work everyday. It is so liberating not have to think about what to wear to work. Scrubs are so comfortable. And I don't have to wear heels. This is a wonderful thing. What other job allows you to walk to work in pajamas and scuffed up shoes?
11. Getting to see those beautiful moments that pass between people. An old lady tenderly stroking her sick husband's face with a withered, arthritic hand. A child whose racking coughs shake his tiny frame, sits comforting her distressed parent. A boy, body piercings chiming as he scurries around the department trying to get water for his girlfriend. It's pretty inspiring, watching how some people cope with stress. People surprise you all the time.
12. Messing with the minds of other people. I love it that I look like a weedy little foreign girl, then I get to say "Hello, I'm Dr TSCD." That seriously messes some people up. Hahaha.
13. Doing what I've always wanted to do in life. I know that the downside of my job outweighs the upside...but there's nowhere else I'd rather be.
1. Long hours and having to work overtime for no extra compensation/kudos. Patients don't care that you've had to cancel your plans for the evening because you've had to spend an hour answering their questions for the 10th time or sorting out their outpatient follow-up. My patients seem to expect me to be free to chat whenever they want and they get angry whenever I spend more time with another patient who happens to be more sick than themselves.
2. A weekend off counts as annual leave.
3. Not being able to take annual leave when I want it - my leave is fixed according to my rota, no requests allowed. This means that I can't get time off to coincide with MDH, or I can only take off one week at a time. There is very little flexibility in my rota for swops - it'll mean that both parties involved will have to work ridiculous shifts.
4. Not being able to eat or drink or go to the toilet whilst on the job - I am perpetually dehydrated, malnourished and anuric.
5. Going for days without seeing sunlight or not being able to sleep at night - I'm either working, or getting over a time lag, or obsessing about a patient, or I've been ordered to do an extra shift during a major incident.
6. Being exposed to infectious diseases at all times. Handwashing and the use of gloves doesn't stop people from coughing/breathing/spraying their lergy all over me. And being continually half-starved, my immune system is not up to scratch. I teeter on the edge of infirmity.
7. The contract. Has anyone ever signed a contract 3 weeks after starting a job? It is a non-negotiable contract which also states that my salary can change without prior notice, amongst other things. Last year, I took a paycut after 3 months (even though I was working the same hours) and there was nothing I could do about it.
8. Constantly looking for new jobs - training posts are only 6 months long. Job-hopping is not an optional extra for me, it's a bleeding curse. I spend all my free time filling out application forms. I do not have job security as a doctor, contrary to what everyone else thinks. I envy all those people who say 'I've been working for this stupid company for 20 years'.
9. Having to do very nasty things to people or to children everyday. Try holding a screaming child down with one arm whilst jabbing it with a needle. To them, I'm suddenly the most evil, cruel person in the whole world and they hate me. Some of the looks I get from the parents sometimes...well, it makes me feel like a monster.
10. Having to meet with angry or unreasonable people and not being able to say "if you don't like it here, just leave and go somewhere else".
11. Watching someone die not because there was nothing else that could be done for them, but because a lack of resources meant that it couldn't be done now.
12. Always having to sit for more exams. There is no end to studying and exam taking in this field of work. Between studying and filling out application forms, I've no time for hobbies. My guitar lies in cobwebs and my singing voice has gotten harsh and rusty.
13. Watching my enthusiasm wane with each passing day. I try my best not to become another bitter and cynical doctor...but it's hard.
14. Watching my ability to make decent conversation wane with each passing day. I try my best not to continually discuss my work with people...then I find that I don't have anything else to say.
15. Knowing that there is no other job that I could do with my training. Can I quit and become an accountant or a banker or a secretary or a journalist or an interior designer? No. I don't have the training or the experience or the knowledge.
16. Knowing that there is nothing else I'd rather do. So I'm stuck here forever, because this is the life I chose. Stupid, stupid, stupid me!
Please wear your seatbelt when you are in the car. Even when you are in the back seat.
Two people. Two cars. Same car accident. One was wearing a seatbelt, one was not.
Seatbelt wearer had whiplash. Went home with painkillers.
Non-seatbelt wearer got thrown out of the *side* window, landed in a field 20 metres away. Both her legs were facing the wrong way when she came to the hospital - broken at the thighs - and that was the least of her injuries. She was still alive...mercifully, she never woke up.
In the 3 days or so I have seen so many very small children with cuts and scrapes on their hands and knees. Most of them are visiting from France with their parents (why they have chosen to come to the UK of all places in this miserable winter weather is beyond my comprehension).
It's strange to hear all these parents talking about how they took their toddlers to see the historical places in England and to see the museums...but all the children are only interested in telling me about the ducks on the water or the funny-looking bugs they found in the park.
It reminded me about this short video I took of a small toddler chasing pigeons in Pisa last year (you can't see the leaning tower in the video, because I was facing away from it). You can hear his parent yelling at him...probably saying something like "will you stop that and come here and be more cultured!".
Always, always, always trust the gut instinct. The gut instinct has never let me down. The gut instinct is what differentiates clinicians from physicians. I am a physician. I let the patient give me the answers. I do not treat X-rays or blood results. I treat people.
Go with the gut instinct. It's quicker and safer. Do not let self-doubt get in the way when a patient's life is at stake. Ask questions and don't back down even if the other person is more experienced. Seniority should not be an issue when a mistake could be made which would worsen a patient's condition.
One of the worst thing in the world is having to tell someone:
1. That she is unexpectedly pregnant 2. That the bleeding and pain is probably not a good sign for the pregnancy
What makes it worse is having to use a translator to tell that someone.
And the translator is the mother-in-law.
It makes for badness all round. Many boxes of tissues were used.
***
Oh yes, and a note for all you husbands out there...
If your wife is having a miscarriage and is in hospital, please try and come from wherever you are and be with her. Or at least talk to her directly on the phone and not talk to her through your parents. And do not talk to her through the doctor!
"Tell my wife that I'm not coming."
No, I will not; you tell her yourself, you scumbag. Are you like 14 years old? This is not secondary school! You're a grown man!
(Note: This fellow actually hung up the phone before his wife could speak to him. I had to tell her myself in the end, anyway. Fortunately, it seems that Mother-In-Law was of the same mind and quickly excused herself to use her own mobile phone outside the hospital - presumably to give her good-for-nothing son a scolding.)
Audits are good. Audits tell us where we can improve in our clinical practice. Audits lead to more audits which also lead to improvements in clinical practice. Audits are useful tools that help us to see how well we are doing in relation to the gold standards of medical care. Audits are wonderful and have no long lasting side effects. Audits are well-loved by many and are not associated with blinding headaches and insomnia. Audits are not at all time consuming or boring and everybody enjoys them. Hooray for Audits!
*discreet cough*
So every doctor in the department paired up to prepare an audit presentation. There were 7 presentations. They were judged by an International Panel Of Judges (one of our consultants is from Ireland). There was a Glittering Prize for the best presentation (a 500gm gold foil box of Marks & Spencer's Luzury Assorted Swiss Chocolate).
And we won!
Yay for us!
Perhaps it had something to do with the fact that I used Large and Colourful graphics in our presentation. (Who can resist large 3-D pie charts or line graphs in various psychedelic colours? I also had flowcharts! With squiggly arrows! And Venn diagrams! There's nothing more classy than a venn diagram.)
Or the fact that I had a lovely assistant (i.e. my co-presenter) who had on a most attractive short ruffled skirt which went perfectly with her 4 inch tall purple suede shoes.
(P.S. Box of chocolates was grudgingly shared with all the other doctors.)
TSCD: So, what can I do for you today? Man: My hand hurts. TSCD: What happened? Man: I punched a wall. TSCD: (not quite understanding) What? Man: I punched a wall. In anger. I punched a wall in anger. I was aggrieved. TSCD: (examines hand) So, you have some bruising over your knuckles. Man: Owwowwoww! This examination is so painful that I am almost going to pass out! TSCD: Okay. You are an idiot and a pansy, but I will get you some painkillers and an X-ray card.
(Five minutes later)
TSCD: Okay, here are some painkill...what are you doing?! Man: I am punching the wall in anger! TSCD: But why? (realises that Man = Shockingly Stupid Person) SSP: I am aggrieved! TSCD: Okay, well, it is obvious that nothing in your hand is broken. You may leave. No X-rays for you. SSP: But what about my painkillers? TSCD: You can't have any. You are obviously not in enough pain because you are causing pain to yourself on purpose. I am not prescribing you any strong painkillers. Go and buy some from the supermarket if you want any. SSP: Aaargh! I will punch the wall in anger on my way out! TSCD: Go ahead, you idiot. SSP: Owwowwoww! My hand hurts again! TSCD: Get lost!
