So for four weeks I'm covering the surgical highcare unit (SHCU) - a 10 bed collection of the sickest surgical patients that aren't quite sick enough for ITU but too sick to be on the wards, or those patients with high risk of post op complications who come straight from theatre.
My day starts around 0745 with a handover from the sister. Around 0800 the entire colorectal team rock up to see their patients so I ward round with them, attempting to interject with useful information gleaned from my handover. The trick is to sound as if I know all about each of the patients from their latest blood results to what volume they vomited overnight, their own individual nutrition plan, what antibiotics they're on, whether their bowels have been open and what pain relief regimen they have.
Once the colorectal team leave I have to triage furiously, doing my own ward round beginning with the sickest patients, examining all the patients, going through their investigation results and acting on anything unusual, while also completing any jobs generated from the ward round such as referrals to other specialties. During this time any of the other surgical teams (or indeed any random consultant, or microbiology, or the nutrition team) might appear to see any of their patients that have landed in SHCU and I'll have to ward round with them. It is nearly impossible to see everyone before the anaesthetist turns up between 1300 and 1400 to start the anaesthetic ward round during which they see every patient themselves and I see them all again.
It is quite satisfying (if a strain on my organisational abilities) having 10 sick patients all to myself, if they're not frankly unwell they're just really complicated. One day last week I had three patients in fast AF by mid morning, and one in pulmonary oedema so I was juggling digoxin loading doses and furosemide. There's a guideline that suggests starting with a beta blocker for fast AF but all three patients were hypotensive so I held off.
Another day I had three hypotensive patients that were clinically dehydrated and one in SVT so I was fluid bolusing one end of the ward and getting the other end to blow continually into a syringe (valsalva manoever which can induce a return to sinus rhythm) while phoning the med reg and trying to collect jobs from the ongoing ward rounds, of which there were three happening simultaneously.
I had another day with two patients that were frankly septic and one having a large fresh PR bleed (which was unexpected given that he had had a panproctocolectomy (removal of colon and rectum) so shouldnt really have had anything to bleed from.
Today I actually managed a lunchbreak! All the patients were stable, and there was no anaesthetic ward round so had a chance to relax.
Monday 2 April 2012
Monday 19 March 2012
Dr Doctor's 12 day stretch.
So I'm currently on a much appreciated week of annual leave following a 12 day stretch of day shifts, a mixture of normal days (officially 8-5pm but often running over till 6 or 7pm) and long shifts which are 8am-8pm.
Daily ward work has been fairly standard, ward rounds every morning followed by jobs and then pre-clerking in the afternoon. The weekend long shifts leave two FY1 doctors covering wards with a total of about 60 patients plus surgical HDU with 10 of the sickest surgical patients in the hospital. The duty consultant or their registrar goes round to see every patient on the wards in between being in theatre. These are very long ward rounds, and they expect us to know all the patients which is difficult if they're not under our team or our specialty during the week.
Weekends can be quite stressful when it's just one of you looking after a quantity of patients that would normally have at least two or three of you. Quite often the nurses (who dont tolerate the phrase "I'm sorry, I dont have time to that right now" at the best of times) dont understand this. An example from this weekend was when I was taking my time to write up the anti-sickness and analgesic medications for a palliative patient rather than attending to the screaming IV drug abuser (admitted for IV antibiotics for his groin and splenic anscesses) in room 10 demanding more morphine (he had already had a large amount of opiate based pain relief and had been mobile for a cigarette several times already that morning so I wasn't particularly concerned about his pain). I hoped somebody had been escorting him outside for his cigarettes as he had a pink cannula rather fetchingly situated on the side of his shaved head in the absence of any other suitable vein! It's not unusual for them to come back in under the influence of something and end up "completely narked" when also given their regular analgesia.
Surgical patients on the whole seem to be rather a lot more needy than medical patients, and there seems to be higher preponderance of slightly unusual people, the sort that refuse to leave the hospital even though they are by all accounts well and very much surgically fit to go home, or those that try to insist on having further surgery. Personally I can't imagine anything worse than being stuck in the NHS Hotel. It smells. There are sick people everywhere. People vomit nearby on a regular basis. People crap nearby on a regular basis and it smells. If you stay long enough you're guaranteed to get a chest infection or a DVT. The food is inedible. You're not allowed to drink (although I was heartened to find a bottle of sherry next to one of our dying patient's bedsides the other day, with a prescription for 25ml PRN on the drug chart).
However many hours I'm stuck there, it would be so much worse to be a patient.
Daily ward work has been fairly standard, ward rounds every morning followed by jobs and then pre-clerking in the afternoon. The weekend long shifts leave two FY1 doctors covering wards with a total of about 60 patients plus surgical HDU with 10 of the sickest surgical patients in the hospital. The duty consultant or their registrar goes round to see every patient on the wards in between being in theatre. These are very long ward rounds, and they expect us to know all the patients which is difficult if they're not under our team or our specialty during the week.
Weekends can be quite stressful when it's just one of you looking after a quantity of patients that would normally have at least two or three of you. Quite often the nurses (who dont tolerate the phrase "I'm sorry, I dont have time to that right now" at the best of times) dont understand this. An example from this weekend was when I was taking my time to write up the anti-sickness and analgesic medications for a palliative patient rather than attending to the screaming IV drug abuser (admitted for IV antibiotics for his groin and splenic anscesses) in room 10 demanding more morphine (he had already had a large amount of opiate based pain relief and had been mobile for a cigarette several times already that morning so I wasn't particularly concerned about his pain). I hoped somebody had been escorting him outside for his cigarettes as he had a pink cannula rather fetchingly situated on the side of his shaved head in the absence of any other suitable vein! It's not unusual for them to come back in under the influence of something and end up "completely narked" when also given their regular analgesia.
Surgical patients on the whole seem to be rather a lot more needy than medical patients, and there seems to be higher preponderance of slightly unusual people, the sort that refuse to leave the hospital even though they are by all accounts well and very much surgically fit to go home, or those that try to insist on having further surgery. Personally I can't imagine anything worse than being stuck in the NHS Hotel. It smells. There are sick people everywhere. People vomit nearby on a regular basis. People crap nearby on a regular basis and it smells. If you stay long enough you're guaranteed to get a chest infection or a DVT. The food is inedible. You're not allowed to drink (although I was heartened to find a bottle of sherry next to one of our dying patient's bedsides the other day, with a prescription for 25ml PRN on the drug chart).
However many hours I'm stuck there, it would be so much worse to be a patient.
Saturday 18 February 2012
Dr Doctor, I take it for walks..
Overheard the following conversation from behind the curtains:
- Nurse, my wife brought me in a few things, would you mind having a look for my glasses in that bag?
- This bag? Alright, let's see..
[squeal of horror]
- Oh God, what's that!?
- Oh that's my toupee.
- Tou..pee?
- Yes, I expect I shant need it in here, I only usually take it for walks.
- You take it for walks?
- Yes, especially when it's cold outside.
- Nurse, my wife brought me in a few things, would you mind having a look for my glasses in that bag?
- This bag? Alright, let's see..
[squeal of horror]
- Oh God, what's that!?
- Oh that's my toupee.
- Tou..pee?
- Yes, I expect I shant need it in here, I only usually take it for walks.
- You take it for walks?
- Yes, especially when it's cold outside.
Thursday 16 February 2012
Dr Doctor - Surgical Twilight On Call 2
One of my FY1 colleagues who is on nights this week told me she cried three times overnight because she'd been stuck seeing several sick patients all at once and the nurses kept pestering her about all manner of minor things like prescribing fluids and writing drugs charts. Some nurses can be very insistent, literally shoving charts under your nose while you're trying to write in the notes, or brandishing a slightly abnormal set of obs in your face or just coming up and talking loudly at you while you're clearly busy with something else.
The trouble is, if the nurse has told me about something, it is then my responsibility to do something about it, not least because the nurse will note down my name and write "doctor informed" in the notes, even if "informing me" has involved yelling "doctor doctor patient has high resp rate" from across the nurses station, then buggering off leaving me to discover for myself that the resp rate is 18 (not that high) but the sats are 76%.
I'm sure I too am guilty of forgetting that the nurses are incredibly busy with other things when I ask them to do several things all at once to sort out a sick patient, but it is frustrating when they come out with things like "I'll finish the obs round in here then I'll give the IV frusemide" [to my patient who is gasping in the corner while all the other patients in that bay are sleeping peacefully].
Yesterday's twilight shift was a little less frantic than the previous two. There was an interesting patient admitted to SHDU, a 70 year old man who had come off his motorbike and fractured 9 of his ribs, several in two or more places giving him a flail segment, and a lung contusion. He was in a lot of pain, unsurprisingly, and my first task for him was to list him on the emergency theatre list for an anaesthetist to put in a thoracic epidural.
Listing someone for emergency theatre involves filling in a form and venturing into the emergency theatre waving said form like a white flag, to be grilled by whichever anaesthetist is on duty. Nobody had really briefed me about quite how to do this so naturally I wandered (not in scrubs) in looking a bit lost and got waved back into the scrub room for being "fully clothed". Cue conversation yelled from doorway to anaesthetist.
I returned to this patient a couple of hours later because I had been asked to repeat his blood gas. I found him to be rather a lot more drowsy than before, and was slightly concerned this may have been to do with the morphine PCA (patient controlled analgesia, IV morphine at the touch of a button) and large quantity of tramadol he had been given. Hid blood gas showed a mixed respiratory and metabolic acidosis with a pH of 7.22 (very bad) and a pO2 of 7 on 15L of O2 (very bad). Erk. Bleeped on call surgical SHO immediately.
He came to see the patient and meanwhile I was called to see a patient with a blood pressure of 211/130 (very high). Now, low BP I know roughly what to do with, acutely high BP is not something I had ever come across on my own. I ascertained that this chap's epidural had been stopped that morning, and he had only just been restarted on his antihypertensive meds that morning. He was feeling sick and in pain and I reasoned that his BP was probably high due to pain and the stopping of the epidural (epidurals lower blood pressure by causing vasodilation).
Having discussed the patient with my surgical SHO, prescribed further analgesia and antiemetics I gave him some GTN spray sublingually and 5mg additional amlodipine and his BP came down beautifully to 130 systolic and he looked much better by the time I left. Even managed to leave roughly on time.
The trouble is, if the nurse has told me about something, it is then my responsibility to do something about it, not least because the nurse will note down my name and write "doctor informed" in the notes, even if "informing me" has involved yelling "doctor doctor patient has high resp rate" from across the nurses station, then buggering off leaving me to discover for myself that the resp rate is 18 (not that high) but the sats are 76%.
I'm sure I too am guilty of forgetting that the nurses are incredibly busy with other things when I ask them to do several things all at once to sort out a sick patient, but it is frustrating when they come out with things like "I'll finish the obs round in here then I'll give the IV frusemide" [to my patient who is gasping in the corner while all the other patients in that bay are sleeping peacefully].
Yesterday's twilight shift was a little less frantic than the previous two. There was an interesting patient admitted to SHDU, a 70 year old man who had come off his motorbike and fractured 9 of his ribs, several in two or more places giving him a flail segment, and a lung contusion. He was in a lot of pain, unsurprisingly, and my first task for him was to list him on the emergency theatre list for an anaesthetist to put in a thoracic epidural.
Listing someone for emergency theatre involves filling in a form and venturing into the emergency theatre waving said form like a white flag, to be grilled by whichever anaesthetist is on duty. Nobody had really briefed me about quite how to do this so naturally I wandered (not in scrubs) in looking a bit lost and got waved back into the scrub room for being "fully clothed". Cue conversation yelled from doorway to anaesthetist.
I returned to this patient a couple of hours later because I had been asked to repeat his blood gas. I found him to be rather a lot more drowsy than before, and was slightly concerned this may have been to do with the morphine PCA (patient controlled analgesia, IV morphine at the touch of a button) and large quantity of tramadol he had been given. Hid blood gas showed a mixed respiratory and metabolic acidosis with a pH of 7.22 (very bad) and a pO2 of 7 on 15L of O2 (very bad). Erk. Bleeped on call surgical SHO immediately.
He came to see the patient and meanwhile I was called to see a patient with a blood pressure of 211/130 (very high). Now, low BP I know roughly what to do with, acutely high BP is not something I had ever come across on my own. I ascertained that this chap's epidural had been stopped that morning, and he had only just been restarted on his antihypertensive meds that morning. He was feeling sick and in pain and I reasoned that his BP was probably high due to pain and the stopping of the epidural (epidurals lower blood pressure by causing vasodilation).
Having discussed the patient with my surgical SHO, prescribed further analgesia and antiemetics I gave him some GTN spray sublingually and 5mg additional amlodipine and his BP came down beautifully to 130 systolic and he looked much better by the time I left. Even managed to leave roughly on time.
Wednesday 15 February 2012
Dr Doctor - Surgical Twilight On Call
So all this week I'm working the 1630-2300 shift covering two surgical wards with a mixture of upper GI, colorectal and vascular patients plus the Surgical High Dependency Unit (SHDU). Trouble is, the nurses do an obs round at 2200 so I get a flood of bleeps about potentially sick patients all of whom need reviewing so it has been impossible to leave on time.
Monday night I found myself literally juggling four sick patients on one ward. Having been bleeped about two of them, one with post op hypotension and another with low urine output, I turned up on the ward to have two more sets of obs shoved under my nose by nurses with typically foreign disregard for my current state of busyness "Doctor this patient has a resp rate of 44." "Doctor this patient is having tachycardia."
Deep breath. I decided to do an "end of the bed test" on the four patients, decide which looked sickest and start with them.
The chap with a high resp rate I had actually reviewed earlier on having looked at his chest xray which had been handed over to me by the day team to check. I couldnt decide if he had a pneumonia from just looking at the xray so had listened to his chest and thought it was clear earlier. Looking at him now he looked very short of breath and quite unwell so I reviewed him again and thought there were probably a few crackles and reduced air entry on one side, but he was wheezy on the other side. He didnt look fluid overloaded. Plan - ABG, oxygen, senior r/v. Although his ABG result wasnt terrible he actually ended up going to the SHDU.
I had had a handover from the anaesthetist about the post op hypotension chap, who had said if he remained hypotensive to do an ECG to exclude a cardiac cause, and not to give any more fluids as he was at risk of fluid overload. He looked pretty stable with a systolic BP of 88 so I asked the nurses to do an ECG on him and on the tachycardic lady while I reviewed the low urine output patient who looked more sick.
She was apyrexial, her BP was stable with a systolic of 120 and her heart rate was 90. Her inflammatory markers werent raised so I thought it unlikely that she was septic. She looked quite dehydrated and said she was thirsty although hadn't been drinking much. She had had a right hemicolectomy and an ileostomy so I checked her drain outputs and stoma output which werent particularly large. I asked the nurses to flush the catheter, started her on IV fluids and returned to review the ECGs on my other patients.
The tachycardic lady was in sinus tachycardia with a rate around 120. Looking at her obs she had been tachycardic for about 4 hours but her blood pressure was stable at 125 systolic. On examination I thought she was very dehydrated, with a very dry sore looking tongue. I decided to give her a fluid bolus, 250ml normal saline stat and see what that did to her heart rate. She did have some bibasal crackles in the chest which always makes me worry about pulmonary oedema but her JVP wasnt raised and she wasnt particularly oedematous so I thought the chances of me overloading her were low, and the crackles were probably due to post op atelectasis (basal lung collapse, common after abdominal surgery).
While that was running I went to look at the hypotensive chap who still looked very well, his obs were all otherwise stable and he wasnt on any massive doses of antihypertensive meds. His ECG was normal. I asked the nurses to raise his legs and call a doctor if his BP went below 85 systolic.
Back to the tachycardic lady. Her heart rate had come down to 105. I gave another fluid bolus and it came down to 94. Reassuringly it seemed I had made the correct diagnosis. Had another quick listen to her chest to check the crackles hadnt got any worse (they hadnt) and by now it was midnight so I handed her over to the night team and headed for home.
I didnt get a chance to have a break for dinner and was starving. I must have looked somewhat forlorn leaving the hospital tiredly munching on a sandwich.
Monday night I found myself literally juggling four sick patients on one ward. Having been bleeped about two of them, one with post op hypotension and another with low urine output, I turned up on the ward to have two more sets of obs shoved under my nose by nurses with typically foreign disregard for my current state of busyness "Doctor this patient has a resp rate of 44." "Doctor this patient is having tachycardia."
Deep breath. I decided to do an "end of the bed test" on the four patients, decide which looked sickest and start with them.
The chap with a high resp rate I had actually reviewed earlier on having looked at his chest xray which had been handed over to me by the day team to check. I couldnt decide if he had a pneumonia from just looking at the xray so had listened to his chest and thought it was clear earlier. Looking at him now he looked very short of breath and quite unwell so I reviewed him again and thought there were probably a few crackles and reduced air entry on one side, but he was wheezy on the other side. He didnt look fluid overloaded. Plan - ABG, oxygen, senior r/v. Although his ABG result wasnt terrible he actually ended up going to the SHDU.
I had had a handover from the anaesthetist about the post op hypotension chap, who had said if he remained hypotensive to do an ECG to exclude a cardiac cause, and not to give any more fluids as he was at risk of fluid overload. He looked pretty stable with a systolic BP of 88 so I asked the nurses to do an ECG on him and on the tachycardic lady while I reviewed the low urine output patient who looked more sick.
She was apyrexial, her BP was stable with a systolic of 120 and her heart rate was 90. Her inflammatory markers werent raised so I thought it unlikely that she was septic. She looked quite dehydrated and said she was thirsty although hadn't been drinking much. She had had a right hemicolectomy and an ileostomy so I checked her drain outputs and stoma output which werent particularly large. I asked the nurses to flush the catheter, started her on IV fluids and returned to review the ECGs on my other patients.
The tachycardic lady was in sinus tachycardia with a rate around 120. Looking at her obs she had been tachycardic for about 4 hours but her blood pressure was stable at 125 systolic. On examination I thought she was very dehydrated, with a very dry sore looking tongue. I decided to give her a fluid bolus, 250ml normal saline stat and see what that did to her heart rate. She did have some bibasal crackles in the chest which always makes me worry about pulmonary oedema but her JVP wasnt raised and she wasnt particularly oedematous so I thought the chances of me overloading her were low, and the crackles were probably due to post op atelectasis (basal lung collapse, common after abdominal surgery).
While that was running I went to look at the hypotensive chap who still looked very well, his obs were all otherwise stable and he wasnt on any massive doses of antihypertensive meds. His ECG was normal. I asked the nurses to raise his legs and call a doctor if his BP went below 85 systolic.
Back to the tachycardic lady. Her heart rate had come down to 105. I gave another fluid bolus and it came down to 94. Reassuringly it seemed I had made the correct diagnosis. Had another quick listen to her chest to check the crackles hadnt got any worse (they hadnt) and by now it was midnight so I handed her over to the night team and headed for home.
I didnt get a chance to have a break for dinner and was starving. I must have looked somewhat forlorn leaving the hospital tiredly munching on a sandwich.
Thursday 9 February 2012
Dr Doctor where is your senior?
So we had a difficult patient to contend with this week. A 23 year old man who had come in with generalised abdominal pain and apparent urinary retention. He had a tendency to roll around screaming in "pain" until someone gave him morphine, which was "the only thing that ever works".
He had several ultrasound scans of his abdomen, all of which were normal. All of his blood results were normal. He already had a urology outpatient appointment booked. We could not find a cause for his pain and were keen to discharge him but last night he kicked off after all of our team doctors had gone home and refused to leave, screaming that we had called him a liar and we had "promised" to find the cause of his pain and urinary retention. He was given some more morphine which kept him quiet until ward round the next day. My registrar asked me to get the urology registrar to come and review him before sending him home.
So I bleeped the on-call urology reg who was of course, scrubbed in theatre. Cue a three way conversation via a nurse ending with him saying he would bleep me back. He recommended we get a contrast CT of the patient's abdomen just to rule out absolutely anything and then discharge him. So I dropped the request form down to radiology, fully expecting it to be refused given the high dose of radiation it would incurr for such a young patient.
Sure enough, I get phoned at 1630 by a radiologist on the warpath:
- Who am I speaking to?
- This is one of the surgical house officers.
- Oh god. [in possibly the most dismissive, unimpressed sounding voice I have ever heard, bar the cardiology reg I pissed off in my first week] Is there nobody senior there?
- No. My registrar is in theatre.
- Well, no offence [some taken] but you dont know this patient.
- Actually I have seen this patient every day for the past week, would you like to hear the story?
- Why are none of your seniors available?
- My seniors are in theatre.
- Right well, this is a massive dose of radiation to give to such a young patient [in a very condescending tone as if I couldnt possibly have known this myself] and all of his other scans are normal so this might be a totally unnecessary investigation. What are you hoping to achieve?
- I understand that, and I agree. We are not expecting the scan to show anything and are hoping to discharge this patient, but the urology registrar requested this scan before discharge.
- Well this is ridiculous! [quite clearly blowing a gasket on the other end of the phone at this stage] We cant just go around pumping radiation into people unnecesarily!
- I understand that. Please can I give you the urology registrar's bleep number so you can discuss this with him?
- Yes that's a good idea. Did he come and see the patient?
- No he did not. [I start to feel slightly uncomfortable that I may be getting the urology reg into trouble here, he'd been really nice to me on the phone, although he really should have come to see the patient]
- WHAT!?? [silence. I'm concerned he may have just ruptured a berry aneurysm and died] Does the patient have a psych history?
- Yes, he is on quetiapine.
- So you're asking me to scan a young man with unresolving abdominal pain with normal test results and a psych history??
- PLEASE can I just give you the urology registrar's bleep number?
So I give him the number and he slams the phone down on me. How unreasonable!
He had several ultrasound scans of his abdomen, all of which were normal. All of his blood results were normal. He already had a urology outpatient appointment booked. We could not find a cause for his pain and were keen to discharge him but last night he kicked off after all of our team doctors had gone home and refused to leave, screaming that we had called him a liar and we had "promised" to find the cause of his pain and urinary retention. He was given some more morphine which kept him quiet until ward round the next day. My registrar asked me to get the urology registrar to come and review him before sending him home.
So I bleeped the on-call urology reg who was of course, scrubbed in theatre. Cue a three way conversation via a nurse ending with him saying he would bleep me back. He recommended we get a contrast CT of the patient's abdomen just to rule out absolutely anything and then discharge him. So I dropped the request form down to radiology, fully expecting it to be refused given the high dose of radiation it would incurr for such a young patient.
Sure enough, I get phoned at 1630 by a radiologist on the warpath:
- Who am I speaking to?
- This is one of the surgical house officers.
- Oh god. [in possibly the most dismissive, unimpressed sounding voice I have ever heard, bar the cardiology reg I pissed off in my first week] Is there nobody senior there?
- No. My registrar is in theatre.
- Well, no offence [some taken] but you dont know this patient.
- Actually I have seen this patient every day for the past week, would you like to hear the story?
- Why are none of your seniors available?
- My seniors are in theatre.
- Right well, this is a massive dose of radiation to give to such a young patient [in a very condescending tone as if I couldnt possibly have known this myself] and all of his other scans are normal so this might be a totally unnecessary investigation. What are you hoping to achieve?
- I understand that, and I agree. We are not expecting the scan to show anything and are hoping to discharge this patient, but the urology registrar requested this scan before discharge.
- Well this is ridiculous! [quite clearly blowing a gasket on the other end of the phone at this stage] We cant just go around pumping radiation into people unnecesarily!
- I understand that. Please can I give you the urology registrar's bleep number so you can discuss this with him?
- Yes that's a good idea. Did he come and see the patient?
- No he did not. [I start to feel slightly uncomfortable that I may be getting the urology reg into trouble here, he'd been really nice to me on the phone, although he really should have come to see the patient]
- WHAT!?? [silence. I'm concerned he may have just ruptured a berry aneurysm and died] Does the patient have a psych history?
- Yes, he is on quetiapine.
- So you're asking me to scan a young man with unresolving abdominal pain with normal test results and a psych history??
- PLEASE can I just give you the urology registrar's bleep number?
So I give him the number and he slams the phone down on me. How unreasonable!
Monday 6 February 2012
Dr Doctor starting surgery.
So last Wednesday was another Black Wednesday, when all the FY1s and a significant proportion of the SHOs swapped rotations. in my hospital, all the FY1s from medicine swapped to surgery and vice versa.
This was quite a shock to the system. I've started in Upper GI surgery, which was my first choice of surgical rotation, partly for the variety and partly that I prefer vomit to faeces (colorectal) and gangrene (vascular), and there might be less need to stick my finger up people's backsides.
So myself and two other equally clueless FY1s were thrown in at the deep end for morning ward round with an exceptionally stereotypical, dragon-like Glaswegian female consultant surgeon who barked things at us.
Surgical ward rounds take approximately one tenth of the time a medical ward round takes. By the time you have found space to write in the notes the surgeon has already seen the patient after the patient after the one you thought you were seeing. Having to scribble down words like "oesophagogastrectoduodenostomy" at lightning speed while remembering all the jobs like requesting CT scans, X-rays, chasing biopsy results etc and trying to understand just what on earth the surgeon has done and why that drain is coming out of there and what the brown stuff/green stuff/black stuff in it might be is pretty challenging.
Afternoons are spent pre-clerking patients prior to their operations. For some reason, somebody thought it would be a good idea for the doctors with the least experience to decide whether a patient is suitable for their operation in a few days time. This involves a comprehensive proforma asking a variety of questions about the patient's past medical history and then examining the patient, sending them for routine bloods including a group and save and reviewing things like ECGs, echo results and chest x-rays, and telling them which medicines to stop prior to their operation.
If anything untoward pops up in the history, exam or investigations we're supposed to find the anaesthetist who will be putting that patient to sleep (difficult as the anaesthetic rota for each week comes out on Thursdays, and is subject to change) to discuss the patient. We have had no real guidance as to what needs discussion and what doesnt, I mean how do I know whether an ejection fraction of 60-70% would preclude someone from having a particular operation. I dont even really know what most of the operations actually involve. Quite a lot of responsibility.
My first pre-clerking came with no ECG, and no echo report, but helpfully informed me that when he had them done that morning his heart had been going really really fast.
- How fast?
- Oh, about 160.
- Do you have any heart problems?
- Dont think so.
- But you're on warfarin, and bisoprolol, are you sure you dont have atrial fibrillation?
- Oh yeah I've got that.
Having spent a good while trying to obtain a further ECG (problems encountered included an inability to stick the ECG dots to the gentleman's chest that was so hairy he looked like a yeti) I ascertained he wasnt in fast AF, or even in AF at that point. Still discussed him with an anaesthetist.
This was quite a shock to the system. I've started in Upper GI surgery, which was my first choice of surgical rotation, partly for the variety and partly that I prefer vomit to faeces (colorectal) and gangrene (vascular), and there might be less need to stick my finger up people's backsides.
So myself and two other equally clueless FY1s were thrown in at the deep end for morning ward round with an exceptionally stereotypical, dragon-like Glaswegian female consultant surgeon who barked things at us.
Surgical ward rounds take approximately one tenth of the time a medical ward round takes. By the time you have found space to write in the notes the surgeon has already seen the patient after the patient after the one you thought you were seeing. Having to scribble down words like "oesophagogastrectoduodenostomy" at lightning speed while remembering all the jobs like requesting CT scans, X-rays, chasing biopsy results etc and trying to understand just what on earth the surgeon has done and why that drain is coming out of there and what the brown stuff/green stuff/black stuff in it might be is pretty challenging.
Afternoons are spent pre-clerking patients prior to their operations. For some reason, somebody thought it would be a good idea for the doctors with the least experience to decide whether a patient is suitable for their operation in a few days time. This involves a comprehensive proforma asking a variety of questions about the patient's past medical history and then examining the patient, sending them for routine bloods including a group and save and reviewing things like ECGs, echo results and chest x-rays, and telling them which medicines to stop prior to their operation.
If anything untoward pops up in the history, exam or investigations we're supposed to find the anaesthetist who will be putting that patient to sleep (difficult as the anaesthetic rota for each week comes out on Thursdays, and is subject to change) to discuss the patient. We have had no real guidance as to what needs discussion and what doesnt, I mean how do I know whether an ejection fraction of 60-70% would preclude someone from having a particular operation. I dont even really know what most of the operations actually involve. Quite a lot of responsibility.
My first pre-clerking came with no ECG, and no echo report, but helpfully informed me that when he had them done that morning his heart had been going really really fast.
- How fast?
- Oh, about 160.
- Do you have any heart problems?
- Dont think so.
- But you're on warfarin, and bisoprolol, are you sure you dont have atrial fibrillation?
- Oh yeah I've got that.
Having spent a good while trying to obtain a further ECG (problems encountered included an inability to stick the ECG dots to the gentleman's chest that was so hairy he looked like a yeti) I ascertained he wasnt in fast AF, or even in AF at that point. Still discussed him with an anaesthetist.
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