Are you sure this is a valid prescription?

Seen yesterday on the PRN side of the drug chart:

Vodka 50mls PO

on the same chart, regular side:

Chlordiazepoxide 20mg QDS

The nurse who picked this up bleeped the pharmacist who briefly did a good impression of a beetroot and then looked like they were about to lay an egg.

The pharmacist's main issues were:

a) Why wasn't this patient (who was an alcoholic) being detoxed?
b) Where did the doctor think they had medicinal vodka in the hospital?
c) What was the doctor thinking prescribing alcohol *and* a benzodiazepine together?

Sadly, the pharmacist left before the doctor arrived to sort out the chart. My favourite part of this was the doctor's eye-rolling and suggestions that the pharmacist was being over the top in getting upset about this. Oh, and then asking around the ward if we knew what alcohol pharmacy *did* stock.

So many of the shifts I've worked over the summer have been guides on what not to do as a doctor. Behaviour-wise and common sensical.

How the sausage is made

This post was inspired by a bank shift yesterday

You're a patient in a hospital in the UK, it's 10am and your consultant has just come 'round on the ward round and told you that you're all better and you can go home! Hooray!

Of course, it's not that simple and the nurse tells you that you need a doctor's letter and some medications to go home with. You smile and say fine, but does the nurse have a general idea when you're going? The nurse thinks you should expect to leave around 2pm, so you call your relative to come pick you up.

So what's happening in the background as you are getting dressed and being congratulated by your ward-mates on your imminent release?

1) Consultant tell nurse-in-charge patient can go home at 10am
2) Junior doctor is told to organise discharge by nurse-in-charge
3) Junior doctor rolls eyes and grumbles about doing it at the end of the ward round
4) Junior doctor promptly forgets entire conversation about this discharge
5) Lunchtime comes and goes, nurse bleeps junior doctor multiple times - gets TTA (list of medications to go home with) and discharge letter by 1pm
6) Nurse notes date on discharge letter is wrong, bleeps junior doctor. Promises to fix letter are made and promptly forgotten
7) Pharmacist gets TTA, processes it promptly
8) Ward gets medications, nurse bleeps junior doctor about discharge letter
9) Nurse fends off irate patient about what is taking so long and how ridiculous it is and how the patient shouldn't self-discharge etc. etc.
10) At 4pm discharge letter is complete. Nurse prints, explains and dispenses TTAs. Patient goes home annoyed but happy (if only to be leaving)

I'd really forgotten how much I hate organising discharges. Give me a sick patient. Give me an oozing, stinking wound. Give tears and fears and innumerate emotional horrors of being in hospital.

Just don't give me a day where I spend it chasing other people to do their job so I can send my patient home. I get so tired of being the face of the machinations described above. Basically, I can't do anything more and yet I get to soak up the anger and frustrations of the patient. It is very, very tiring.

Where do we go from here?

I've not blogged in a while and I feel pretty bad about that. It undermines the first rule of blogging, which is "Always Be Creating Content" (he said, paraphrasing Glengarry Glen Ross).

That said, it's been a busy few weeks for me. There were end of year results which were thankfully passes across the board. My school gives you percentages, the mean, the pass mark and (as I think I've mentioned before on this blog) a mark of A for acceptable, CC for cause for concern or U for unacceptable. So, for the first time in a while I'm a straight A student, though in real money I'm a slightly above average student which I'm totally happy about.

It wasn't until I received my grades for this year that I realised where I was in my life, academically speaking. I'd approached medical school with a "I wonder how far I can get" attitude - Which is to say at every step of the way I've not been living and dying by the result. I passed the GAMSAT (the Australian version of the MCATs) and was pleasantly surprised. I passed the interview and was pleased again, but I hadn't walked in with the fire of a zealot in my eyes (which I think helped - some people want to be a doctor so much it hurts their chances). Repeat for every exam so far, apart from this last set. I guess that previously I have been a nurse in my mind. Like some kind of interloper, a spy from the wards seeing how the other half live. Learning about the bigger picture beyond bedpans, food charts the myriad other tasks of nursing.

Not that I wish to denigrate nursing, far from it. Whenever people ask about why I went from nursing to medicine (something that happens with regularity on the wards whilst I'm bank nursing, I've discovered), my answers fail to satisfy. The best I can come up with is that I want a different set of challenges. The stuff that really stresses me out in nursing is organising discharges and chasing down junior doctors to remind them to do paperwork or arranging transport or chasing pharmacy for drugs I need sent up *now*. It was stuff that would forever plague me as a nurse and really took the shine off the stuff I genuinely enjoyed - people and their problems.

I'm sure there will be plenty of paperwork BS in doctoring, but it also opens up a world of other challenges that I think will outweigh the new stresses.

The point I'm trying to get across in a ham-fisted way is that having passed the first year has made me realise that I am all in. I really want to be a doctor and I'm less a nurse than I was this time last year. I am changing. There will always be a part of me that enjoys the intimacy that nursing affords, but I am becoming Other. It'll be interesting to see where this goes.

First Bank Shift

"Everyone gets everything he wants. I wanted a mission, and for my sins, they gave me one." - Capt. Willard, Apocalypse Now


"Hi, Absentbabinski? Are you still available to work tomorrow?"


It was 8pm on a Friday night and I was just starting on my first drink. I could say no. I could get my drink on and have a lie-in tomorrow. I could also start paying my credit card bill off.


"Sure, what ward?"
"Jeremy Kyle - It's Elderly Care (ah, shit) or there's A+E?"


I've never worked A+E and I'm not cleared to give IV meds at St Clabert's, so I'd end up being an annoying, over-paid HCA. I guess it's eldery care, then.


"I'll take Jeremy Kyle. Long day?"
"Long Day, 0730 start"
"Okay, thanks"


A quick bit of mental arithmetic tells me I'll have to get up a bit before 6am. So time to stop drinking, get my Best Dress together and pack my lunch.


I end up in bed at 10pm (a personal best for me), dreading a ward full of crazy old people and staff who couldn't care less. It's a bit of an open secret that (at least in the NHS) elderly care is staffed with either the most caring, skilled and professional nurses who will always be ready to help or... Well, people who aren't the above.


Cue a night of broken sleep and fear.


When I get on the ward the night staff are smiling. Smiling. They had a busy night but they're friendly and helpful and explain how the ward runs. They point out the changing room and when handover will start. I quickly realise they are the former of the two classes of nurses and I think "I'll be able to do this".


We get handover, I introduce myself to my patients and grab a drugs trolley. I've got two patients with IV Abx, but everyone else is on the usual blood pressure meds, anti-arrythmics and laxatives. I can do this. I only have to argue with browbeat encourage one patient to take their tablets. My patients are by and large lovely. I take waaaay to long to finish my drug round (my motto for the day is "I haven't done this for six months!"). There are only a couple of washes I do because the HCA I'm working with is efficient (more so than I am) and industrious. I get two admissions but they are straight-forward, old people who've fallen down. As per elderly care I have more than my fair share of pooey bottoms but I don't care - in fact on some level I like it. It's one of the bits of nursing I've always loved, helping someone do something that they can't do for themselves. And making the experience as normal and natural as possible. 


The shift was really good. I liked the people I was working with, and to their credit they decided I wasn't that much of a liability and asked if I'd like to come back next time they're down a pair of hands. 


I said "sure".

What are you afraid of?

Mrs Absentbabinski managed to score some free tickets to "Ghost Stories" this week. It's a play which is a little slice of genius and genuinely scary in parts. One of the stories (and I don't really think this is a spoiler) involves someone being awake and at work in the early morning and it made me think about night shifts and the quiet terrors they can generate.

I was reminded of the numerous night shifts at St Clabert's hospital (name changed to protect the... Innocent?) Generally once the excitement of drug rounds and cups of tea had settled and people were dropping off to sleep, I would take wandering around the ward (if I had nothing more immediate to do). The ward was divided into 4 six-bedded bays, one per nurse. I would slip into mine and sit in a chair at the far end of the bay and just listen to the breathing of my charges.

Around 3am I am fairly sure that there is some nadir of lots of the hormones that keep the crazy voices out of your head. At this time, if I had nothing more pressing on my mind, I would become convinced that one of my patients would try and die on me. It was irrational and I knew this. But I was sure that something was terribly wrong, so back I would walk, into the bay and I would stop at the foot of each bed listening and playing the beam from my pen-torch over the patient, just to sure.

I would also worry that there was something outside, that is to say that out in the grounds of St Clabert's, something evil was pacing around, just waiting for an unsuspecting nurse to look out of the window and see it and... Well, whatever would happen would be awful. Go figure.

I don't miss night shifts, and ironically I think the things that really should have got my pulse racing (the 3am biochemistry abnormal results, the haematemeses, the  people who would go off (mentally) the minute the sun went down, these things never really scared me. They were tangible and I was trained and/ or experience enough to be able to deal with them. The occult, hidden (and often ridiculous) things that the night holds, they pressed all the right buttons in my lizard brain that had been left running the ship whilst my higher functions had gone off for a nap.

Where have you been?

Everyone just wants to have a good time

When I started this blog I had such high hopes of being able to update regularly and for the first few months I think I did okay. Then revision and associated exam pressure descended on me, and you know what? Med School is *hard*. And revision takes *a lot* of your time, trust me.

Anyhoo, I've been mulling over stuff to write now that the holidays are over and I have 24 hours to breathe before school starts again tomorrow. I'm not the most inventive chap on the planet, so here's a couple of lists for you:

What I've been doing:

• Revising
• Having my first proper exams
• Getting very, very drunk
• Getting my results (passed, but need to pull some grades up to stay in a good place)
• First Christmas as a married man (a lot of fun - combination of family traditions from both sides, with a little something that is just us)
• First NYE in London that I've not been working
• Planned out and tested my riding route to school (Father Christmas brought me a bicycle so now the road is my friend and I am a vision in Hi-Viz orange)
• Playing a bit of World of Warcraft (Don't judge me!), though this stops today because, well, I can't trust myself to not play it too much!

Things to come (pre-loading worries for the new year)

• Actually getting some nursing shifts at my new hospital (Lost forms, general apathy towards the notion of work and hospital bureaucracy have all working against me for the past few months)
• First OSCEs (getting to be examined on skills I've been rushed through - yikes) 
• Essays, essays, essays
• Money worries (I know this will be part of the leitmotif of medical school, but that doesn't make it any easier to deal with)
• New PBL groups! A chance to get to know another six of my coursemates a little better than before. (Something I'm actually looking forward to!)
• Losing weight - The scales are no longer my friend and nor is the app on my iPhone that declares me to have a BMI of 25.1 - I am now overweight. Boo to that.

I've not made resolutions, because I figure I'm only going to keep on doing something if I either enjoy it and/ or want the results of it enough. I'm not sure that promising to do/ not do something really works for me. 

I hope the people who read this have had good times in the past year and will have even better ones in the upcoming 12 months.

Of roles and expectations

I've just finished listening to another excellent episode of Pseudopod, a weekly podcast of horror short stories and this week's was particularly interesting for me. It focuses on a woman who comes to a village under the guise of helping when in fact she has a darker motive.

Alasdair, the host of the podcast, does a wonderful job (as always) of deconstructing the themes of the story. For anyone in healthcare they are juxtaposed between being an everyday part of the job and so very important that if you stop and think about it, our responsibilities are staggering.

The patient will see you as a caraciture

People put their lives in our hands and, more often than not, accept that whatever we do for them or ask them to do is in their best interests. When I push the drug trolley around people accept that because I am dressed like a nurse, seem quite comfortable and friendly, I must be giving them the right medication at the right time etc. etc.

Every nurse I know has made at least one drug error.

Every doctor I know has made at least one drug error/ misdiagnosis.

And yet they come to us. Because we look the part, because they believe in us, our uniforms, our stethescopes, our strange language. There is another component, I think. We have entered into a social contract. We have chosed our roles and promised to fulfull them to the best of our abilites. That, I would argue, is the reason people come to us.

It is both a privilege and a responsibility.

Creative Writing?

He lay in bed, staring at the ceiling and knew he had to go back to work.

It wasn't that his current life was easy or that he especially wanted to go back to the proving ground of the wards, but he knew that going back was important - both financially and because he felt himself getting soft.

As his wife lay with her head on his chest, gently twitching as her breathing became deeper and slower, he looked up at the ceiling, his eyes burning like coals. He ran through permutations, likely complications he had been schooled in: hyperkalemia, hyponatremia, common analgesics, IV fluid prescriptions, the contents of the drawers of the crash trolley, urine output, FBC, biochem, coag, CVC management, venepuncture - the list rolled on and on in his mind.

His wife moaned in her sleep and turned over, freeing his arm and allowing him to bring both hands across his chest. Still staring up at the ceiling in the dark of their bedroom, his mind wandered on. He knew that going back to the wards meant going back to the places where people went sick, where the job ground you down to a fine powder that could be, and often was, blown under the door at the end of a shift. MAU, HAU, Acute Elderly Care, Respiratory Medicine, these places wouldn't be easy and he would earn every penny, every shift.

He realised he hadn't exhaled for what felt like a lifetime. Lying there in the dark, he had held his breath as his mind raced and ran over the likely issues that would arise on a Saturday night shift on an elderly care ward. And he wasn't scared. He needed the money, he was good at the job and for better or for worse, he missed the satisfaction of handing over his patients at the end of the shift and feeling like he had done something useful with the last 12 hours of his life.

He knew it was time to go back.

One thing I have in common with Don Draper

Last night was a night out at The Blues Kitchen in Camden which was pretty awesome. It's quite boutiquey and didn't get crazy busy which was nice. There was some great food, proper American Southern fare and some great drinks particularly the Old Fashioned that I spent most of the night drinking. And unsurprisingly the music was blues, which makes for good background noise when you're eating, drinking and chatting.

I'm quickly beginning to realise that this kind of thing will have to be a once in a blue moon event as I am now coming to the end of my last paycheque. From here on out it's student loans and whatever I can get from the occasional shift - although I'm still yet to actually get on the staff bank.

Transitions

An excellent and thought-provoking article on the Student BMJ detailing one nurse's experience of becoming a doctor and returning to her department with different workload and demands:

CCU sister to CCU junior doctor

I hope I keep writing long enough to produce something for a journal like the Student BMJ.

Show me where it hurts

"Doctor! Doctor!"

I sigh and without even turning 'round say loudly "I'm a nurse"

"Oh! Right! 'Course you are! Well, I mean, I'm in pain, is there anything I can have? I mean, doctors wouldn't know about that, would they?"

Charleen's unintentional Uriah Heep impression doesn't warm the cockles of my heart. She came to us ?Pancreatitis ?EtOH abuse, known ex-IVDU. Now I am not the kind to refuse analgesia to anyone - pain is pain, you can't judge another person's pain, period - but there is something frankly funny about someone who can sleep all morning after their a.m. methadone and then be unfortunate enough to wake with "terrible pain" in their abdomen and an accompanying limp that seems to have manifest itself. Luckily for Charleen, she IS able to have some Oxynorm. It is as much as I can do, not to roll my eyes to show my lack of surprise.

As I say, pain is pain. I do not tarry to get someone pain-killers, even the more suspect actors amongst our current crop of patients. I do, however, find it rather tiring when people make these grandiose shows of how they are in pain and can't I do something, please, and oh it must have been 2 hours/ 4 hours/ 6 hours since their last dose of oxynorm/ morphine/ diamorphine etc. etc. Just tell me you're in pain. We both know that you've been watching the clock, that you know *exactly* when your last dose was and, yes, that paracetamol will in no way improve the terrible and sudden pain you are in.

Pain is, as my lecturers might have said, a vital sign and the symptoms of which vary from person to person, aetiology to aetiology. Maybe you really are in pain, maybe that potent opioid is just a bit moreish, honestly, I don't care if it's the latter. It just means that I have to go hunt down the CD key, another RN and interrupt whatever it is that I'm doing, so you may have to wait a bit.

I don't want to come across as some cold-hearted bastard, I do really have a personal interest in pain - if I'd stayed in nursing it would be something I could see myself specialising in. Junior doctors don't really understand how to prescribe analgesia in my experience and more often than not don't understand that morphine is not going to solve all kinds of pain - and isn't without its side-effects. This often leads to people being left in pain, whilst I apologise profusely and bleep the doctor to get something more written up. I'd ask of all doctors, when writing the drug chart up, if you can please give me some diclofenac or codeine or dihydrocodeine or tramadol on the prn side, if only so I don't have to see one of my patients in pain and me helpless to do anything about it. I know that some people are not suitable candidates for more potent pain-killers (liver damage, head trauma, renal insufficiency, whatever) but that doesn't mean they have to run the risk of being left in pain.

 I hope I remember all this in years to come, if only so I don't (as has happened to me in the past) shuffle up to an RN and ask, plaintively, how tramadol should be prescribed.

Hobbyist Nursing

"Just when I thought I was out... they pull me back in." - Michael Corleone (Godfather III)


"Oh hey, you're back so soon?"
"Wow, guess you just couldn't stay away, huh?"


The 'phone rang at 7 o'clock, the number said "Blocked" and I knew it was the hospital. I'd been umming and ahhhing over booking a couple of shifts with NHS Professionals next week to get a bit of cash and to keep my hand in, but this was a pleasant(ish), surprise. One of my colleagues apologised for waking me and wondered if I could come in. I stared at the ceiling, counted to 3 and said "yes". Time enough to brush my teeth, grab a clean uniform, pack up my lunch and kiss my wife goodbye. She sensibly muttered something about "having fun" and went back to sleep. I ran to the bus.


Coming back to work felt nice. I'd been getting a little misty eye'd about nursing watching Nurse Jackie and it was great to take handover, plan my immediate to-do's and then start the drug round. I really enjoy going through the obs, the drain charts, looking the patient in the eye, saying "Good morning, my name is AbsentBabinski and I'll be looking after you today". Generally they smile back and say good morning and you get a sense of them.


My heaviest patient was a guy who had suffered a stroke intra-operatively and had been left with reduced strength throughout. I helped him with breakfast and it was nice to be doing this for another person, the simple, important stuff. I guess I'd forgotten in the run up to med school how satisfying and intimate this kind of thing is. We chatted as I spooned up porridge and I then I gave him a wash. My lecturers at nursing school had always waxed lyrical about how we were so lucky to be involved in such intimate aspects of care; I had always proposed the notion that they *really* needed to get back on the wards and find out how things worked. I'm not saying that I totally agree with them now, but pulling bank shifts, it feels like a lot of the pressure is gone and I can practice my nursing care in a different way. I feel like I'm doing it as a hobby which means I can take things to a level of detail that perhaps I couldn't when I was ward staff and dealing with the crap that goes with it.


And it was nice to see everyone again, see one of our junior staff take a shift in charge and, frankly, do okay at it. Probably better than my first time in charge!


THIS JUST IN: My med school have *finally* confirmed my place for this year. After so much jumping through hoops and form filling, I got an email from UCAS today saying the uni have confirmed my place, so watch this space!

My new Favourite Thing

I know I'm late to the party with this one, but I've finally started watching Nurse Jackie and I think it's wonderful.

If you suspend your disbelief about a few issues (certainly somethings would be impossible in the UK and they seem like the kinds of things that would be impossible in the US), it's a well-written and touching show. It's bleak, with dark comedy and a troubled protagonist. The titular Nurse Jackie is an RN with a drug problem, two men on the go (one is her husband, with whom she has two children) and dopey - if well-intentioned - student nurse in tow.

The  show really picks up on a lot of things, such as the peculiarities of the relationship between doctors and nurses, the way that nurses are important for making people "better" in a more complete way than the doctors, how shift work can make your real life seem like just something that happens when you're not at work and how you can't save them all.

If you've worked as an RN, you'll feel well represented here, and probably enjoy the dark humour that drives so much of this show. I certainly do.