Dr Doctor please fill in the death certificate.

So today I had the responsibility of filling in my first death certificate and cremation form. The patient was a 75 year old lady who had come into the Emergency Department with sudden onset severe headache and collapse and was found to have had a massive unsurvivable intracranial haemorrhage. She came to ITU for some TLC and palliation in the absence of anywhere else for her to go and passed away peacefully a couple of days later.

Filling in the cremation form is a fairly long process as it has to be very detailed because once the body has been cremated there's no reassembling it to perform any further post mortem tests. The doctor also gets paid around £80 for taking the time to fill it in - "Ash Cash".

Part of the process is to examine the body (which I wasnt quite expecting) so I took a rather apprehensive medical student to the morgue for moral support and was met by an utterly stereotypical morgue assistant with somewhat squinty eyes and an unusual gait. He led us into an enormous fridge lined room and located my lady who, typically, had been placed in the top slot of a four body high fridge. "You'll be wanting some steps," he growled. I looked up to the top slot and had visions of me having to clamber on top of the occupants of the other shelves to examine my lady. "Yes please".

The steps turned out to be ancient and rickety so I spent the duration of my examination wobbling and earnestly trying not to fall on top of the body. The patient looked as if she were asleep with her eyes open, and felt extremely cold and rubbery when I was feeling for a pacemaker. Having performed a "full external examination", I thanked Lurch and we left, to go and fill in the rest of the paperwork.

Dr Doctor my EMG is farting!

We have a very interesting patient on ITU at the moment, who presented with severe rhabdomyolysis (muscle damage) leading to leakage of myoglobin (muscle protein) which caused severe renal failure (because it damages the kidneys). He is interesting because nobody can work out quite why this has happened to him.

One of the exceptionally intelligent consultant electrophysiologists came to review him and test the nerve conduction in his muscles. This involved attaching electrodes to the skin and stimulating the muscles and turning the response into a wavy line pattern on a screen and into a sound signal. He happened to be doing the test during our ward round so we all gathered around to watch.

He checked the monitor, turned the volume up and sent a signal to stimulate the muscle, and there erupted from the machine at about 60 decibels what can only be described as an enormous, prolonged bout of flatulence that echoed around the otherwise relatively quiet ITU! It almost awoke most of the sedated patients, and agitated the poor chap in the next bay to such an extent that he extubated himself! Poor thing looked ever so confused.

Matters were not helped by me being the only one who seemingly could not control my giggles, and the registrar who offered a finger with the old adage "pull my finger" as the seasoned consultant repeatedly stimulated the poor patient's muscle with the same effect, earnestly explaining how this noise meant the patient may well have myotonic dystrophy.

Copy and paste the link below to hear something similar.

http://www.youtube.com/watch?v=xMAu6sZ7ROs

Dr Doctor please refer this patient..

Patients generally land in ITU with a complicated medical history and numerous ongoing problems, some of which may have been investigated in a completely different hospital. The challenge is often to obtain the relevant scan report/microbiology result/clinical opinion from said hospital, in as few moves as possible. This involves a LOT of time on the phone, and much use of the ladies on switchboard.

Yesterday I was tasked with obtaining scan reports and haematology results from my patient's first hospital and then referring them to the haematologists in our hospital. This involved a lot of talking to switchboard. Now on the whole switchboard ladies are fabulous, but yesterday I kept getting through to World's Grumpiest Operator. When I asked to be put through to Hospital X, instead of pushing the one button that would have transferred me simply and easily she instead gave me the direct dial number in a disparaging tone and slammed the phone down. Obediently I used the direct dial number each time I needed to get through to Hospital X the numerous times it took me to get the information I needed (or rather discover the haematology results arent back yet and the scan report is still unverified). Then it was with trepidation that I had to phone our Switchboard to get the bleep number of the on-call haematology registrar which World's Grumpiest Operator snapped down the phone at me in such a way that I almost apologised for not having already known the number myself.

So I bleeped the number and who should phone back but a similarly grumpy grumpy chap who introduced himself as the mumblemumble registrar. Considering that I had managed to get hold of some sort of registrar and on balance they were probably from haematology I proceeded to present the case, emphasising our concerns over the patient's low platelet count and low white cell count and low haemoglobin and finished by saying we would really appreciate it if he could come and review the patient. There was a long pause and then a somewhat exasperated "You do know you're talking to a UROLOGIST right?" How embarrassing - completely wrong person, and a surgeon at that - they're far too busy to listen to pointless referrals! Cue much flustered apologising.

Who knows, maybe he'd also pissed off World's Grumpiest Operator and she decided to get a rise out of both of us!

Dr Doctor I've drunk antifreeze!

The ITU team often gets called to the Emergency Department to assess patients who may or may not need not be managed in ITU. Today's offering was a 45 year old gentleman who had imbibed nearly a litre of antifreeze the previous day and decided to keep quiet about it. He eventually started feeling unwell and told an ex-partner (there's always an ex-partner) who phoned his parents who brought him to hospital.

When we saw him he had fairly deranged blood gases (was moderately acidaemic with a low PCO2) and was hyperventilating to compensate. So from a physiological point of view, quite an interesting case. Helpfully he had washed it all down with a bottle of red wine, and, ironically, alcohol (ethanol) being the antidote to antifreeze had slowed down the process of poisoning himself.

It's interesting the effect self harm cases has on the medical team. Truly suicidal people tend just to get on with it and are sadly found deceased or beyond help. Similarly truly depressed people tend not to tell anyone about how bad they're feeling. The Emergency Department has to deal with a huge number of people "crying for help" on a daily basis, taking ineffectual overdoses or cutting themselves and presenting immediately for TLC. The medical team's duty of care means a lot of time and resources are spent patching these patients up and either referring them to mental health services or discharging them home where they become down and desperate and repeat the cycle of turning up at hospital where people will listen to and care for them. It can be hugely frustrating trying to help somebody who doesnt want to be helped or who are perceived as "attention seeking".

Mr Ethylene Glycol was quite difficult to manage, partly due to his co-existing needle phobia not going well with the requirement to obtain several blood samples for ethylene glycol/methanol levels (in fact the lab rejected the samples saying they "dont do ethylene glycol or methanol levels"), partly because by this point he was realising the seriousness of what he had done and was feeling very unwell. While it is understandable that the chap was frightened and most of his acting up was probably due to this, it is also very difficult to continue to empathise when you know you have to get that needle/line/catheter into him in order to administer the correct treatment.

Speaking of treatment, there's a new antidote to ethylene glycol called fomepizole which costs £4000 per vial. Apparently it works better than ethanol (by irreversibly inhibiting the relevant enzymes) and is thus the best treatment for the patient, but with the NHS needing to save money perhaps there would have been justification for simply filling the chap with vodka! Indeed most Emergency Departments have a bottle of some spirit somewhere for the antifreeze/methanol drinkers out there, and not for the stressed out doctors.

Dr Doctor there's rice in the ET Tube!

Have somehow landed myself four weeks in ITU. Being essentially supernumerary I get to jog around the hospital with the SHOs whenever the cardiac arrest bleeps go off. Often, we arrive on scene and the patient is actually fine, either because the fantastic medical team have got there before us and fixed the patient, or (more often than not) a patient has prostrated themselves in the main entrance and receptionist has interpreted a faint or a reluctance to move as a cardiac arrest.

Had 3 arrest bleeps in the space of about an hour yesterday, one was a post lunch vasovagal episode in an elderly chap (medical registrar's advice was "administer less lunch"), one was a patient with renal colic on the floor in main reception (needed some analgesia and a porter to urology) and the last one was a chap who'd managed to simultaneously choke on lunch, vomit everywhere, aspirate and start fitting. Cue real ITU action involving securing the airway by RSI and intubation, which was made much more difficult by the resurgence of lunch from the lungs. Much suctioning later and he was ready for an arterial line placement and transfer to CT for a brain scan. The chap was ventilated on ITU overnight and extubated this afternoon and not looking too bad. His lunch continues to resurface periodically.

Conclusion - hospital lunches are dangerous.

Dr Doctor please speak to the family.

In elderly care a lot of bad news tends to get broken. A lot of patients sadly come to the ends of their lives on these wards, mostly because they've just been living for a very long time and have diminished reserves and multiple co-morbidities.

One lady of 95 was admitted with a stroke a couple of weeks ago and managed to acquire an infection of some sort. She was really very unwell and probably coming to the end of her life and it fell to me to talk to the family about possibly going down the palliative care route if she deteriorated further. I had mixed feelings about being the one to do this. On one hand, I probably knew her the best out of my junior doctor colleagues, but then I am the most junior of my junior doctor colleagues. It's a powerful position to be in, with the family looking to you for answers to their questions, and to have the authority to explain that we wouldn't continue active treatment if their mum takes a turn for the worse. I felt slightly out of my depth, as it wouldn't be my decision to discontinue active treatment, and as I'd only been a real doctor for two days had never had the opportunity to lead such a conversation before. If I said the wrong thing in the wrong way the whole encounter could go horribly wrong and the family's faith in me and in our team could be diminished.

So I fell back on my commuication skills teaching from medical school. Step 1: find out what they know already. This turned out to be a good strategy because it meant the relatives actually did all the talking for a good 5 minutes. Cue an outpouring of the story so far and their feelings, which allowed me to pick up on the fact they already knew she was DNAR and they already knew she'd had a very big stroke, and they already knew she was very unwell. This gave me a good link to start talking about "if things get worse, keeping her comfortable", which they took on board very well. I was also able to explain what were doing for her in terms of treating the infection, which gave them some reassurance that we hadn't given up on her.

Dr Doctor what about fluids?

Day two and I'm getting the hang of prescribing fluids. Essentially working on the principle that low sodium => normal saline, high sodium => dextrose (but make sure they have some saline at some point, and some potassium at some point) and low potassium => haartman's. If patient on certain drug regime that needs certain fluids, refer to nurses. Maintenance fluids in fit young patient 8 hourly, fluids in small, frail patient with CCF 12-18 hourly. If 1L bag finishes in the middle of the night write up another bag so night team arent bothered by unnecessary bleeping. Seniors, feel free to comment with additional advice.

Had episode of SVT upon spotting the "shit's above the seagull sign" (as in, pulse rate higher than systolic BP) on a little old lady's chart. Informed registrar who suggested I assess her for fluid balance. Wasnt quite sure what this meant but went to examine her. She was GCS 15 and looked well. Heart rate (at palpable radial pulse) was not as high as obs suggested. BP was not as low as obs suggested. BP did not decrease on standing (in fact in increased which is good going for an 80 year old). Tongue looked dry and skin turgor was decreased, cap refill was 3 secs. So she wasn't shocked but needed fluids. My heart rate returned to normal.

DrDoctor dont you know anything??

And here it is, Wednesday 3rd August, affectionately known as the Day of Death amongst seasoned nurses and senior clinicians, when all the brand new F1 doctors are let loose on the wards. Having spent five years pretending to be a doctor and one month in limbo between finals results day and officially starting work amused at being called Dr Doctor by friends and family, to find myself with vast quantities of responsibility in the form of prescription writing (as in, authorising the administration of a substance that will actually change that patient's physiology), assessing patients (as in, in order to decide what on earth to do with them) and writing in the notes (as in, without the understanding that signing off as a medical student would mean everything I had written would be entirely disregarded by anyone wanting to know something relevant about the patient). Naturally I had spent my entire month off celebrating, being on holiday, and forgetting everything I had learnt for finals. I did however find the above diagram helpful.

What I hadn't realised, was that not only were all the F1 doctors starting, all the SHOs were changing jobs as well. So everyone I had got to know during Shadowing Week (usually unpaid opportunity to practise how to look dazed and confused on ward rounds, run around in a disorganised fashion trying to find forms you have never seen nor heard of, and remind oneself what patients look (and smell) like) had disappeared and somehow I became the junior doctor that new the most about how our particular ward/hospital worked.

I found myself accosted by a nurse informing me that "the patient's heart rate has gone up". "How high?" I asked, frantically trying to remember something about this particular patient. "130". The nurse then looked at me, clearly expecting me to know what action to take. "Er.. maybe needs an ECG?" Having made the nurse look satisfied with a vaguely sensible answer she disappeared, and came back brandishing said ECG at me. Thankfully my pattern recognition kicked in and I spotted he was in fast AF. And then I found myself checking the notes for a previous ECG (it was new AF), assessing him for conscious level, SOB, chest pain and signs of shock and concluding (having checked with the friendly registrar) he was probably stable enough to go for the CT that the porters were hovering about waiting to take him down for. Cue long 40mins with intermittent imaginings of him arresting in the scanner. Wrote up digoxin and vowed to take blood (to check for electrolyte disturbances and markers of infection, did he have a CXR?). Patient returns alive and back in sinus rhythm. Crossed off digoxin and breathed sigh of relief. Maybe this whole responsibility thing wont be so bad after all..