A break from your (ir)regular programming

Myself and Mrs Absentbabinski are on hols this week in Malta, so no posts of any consequence for a few more days. It is lovely and if you like swimming in the Mediterranean sea and 32 degree (celcius) days of unending sunshine, I can highly recommend it.

I dare say there will be a debrief post and a few pics when I get back. Assuming London hasn't been razed to the ground.

In the meantime, "Saha" as they say over here.

- Posted using BlogPress from my iPad

London Riots

Although the news has been full of them, the London riots have ended up being more rumour than riot for me. I have passed damaged shop fronts on the bus and I have seen footage on the TV of violence, arson and ineffectual policing, but so far I guess I have been lucky enough to not have them directly effect me.

Working at my hospital yesterday, the day was full of rumour, half-truths and supposition which I found myself getting drawn into more easily than I expected or wanted. They were boarding up the high street, then there was a riot on it already, then that was discounted. Then there was talk of other places being targeted. Nothing to support this other than something heard from someone else who had a friend who knew about it. It's weird how the contained group of nurses all fell to recirculating rumour in lieu of fresh information. Then the hospital quietly advised non-essential personnel to leave by 4pm and said they would be locking the main gates before night fall. I began to feel ever more uneasy. 

From the third floor of the hospital I could look out over South London all the way to Canary Wharf and it was amazing to me how there was no difference I could see. Life was just rumbling on, same as it ever did. When my shift ended I legged it out of the hospital and headed to the train station. Every group of people, no matter how innocent they looked, made my spidey-sense ping and it was all I could do not to sprint for the train. As I got to the station I was passed by two horse carrier lorries, blues and twos going and zooming off to an incident somewhere. On the platform I overheard a group of police officers on their way to work debating whether or not annual had been cancelled.

My wife had been working up in North London in a shop and had had the police come around and tell her to shut up shop and go home. In the middle of the afternoon. She had tried to do a bit of food shopping on the way home only to find all the supermarkets by us shut and some even boarded over with plywood in preparation for violence.

I am torn between worrying about the next few nights and thinking that this will blow over soon enough. The Met have made lots of noise about intensifying policing in the capital and their no-nonsense approach to public order offences is well known around the UK. They are issuing plastic bullets and allocating water cannon.

I'd also like to raise my voice to join the choir of Londoners appalled by the behaviour of a violent and antisocial minority. The best description I have come up with is an amalgam of disenfranchised people, who have been raised on a diet of mass consumerism, with nothing to lose and little fear from prosecution. Arguably a very dangerous combination. That there has been such a united front against these people is something which gives me hope for the city and the species in general.

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.

Because it's Friday...

And I'm a total sucker for a girl with a uke. Sue me:

She has, I think, one of the most tender voices. And if you can spare another 2 minutes:

Hyperarousal

A lecturer this term stated that, physiologically speaking, you can only maintain an adrenaline-fuelled state of hyperarousal for about 60 minutes. This was disputed by some of the ex-soldiers in my class, but I guess for civvies like myself, it sounds about right.

I held tightly onto this when the OSCE's came around. Written exams never provoke the same level of sympathetic response in me. It's not because they're a "you know it or you don't" event so much as they're a "sit on your arse and only move your hand event".

OSCEs by comparison are a full-systems-go-hello-my-name-is experience with actors or simulated patients and an individual examiner. OSCE stands for Objective Structured Clinical Examination and is just that. There is a task to be completed. You're running through mental check lists: Look, Feel, Percuss, Auscultate if it's something like a cardio exam or Passive, Active, Resisted when you're examining someone's wrist and elbow or even the classic History of Presenting Complaint, Medical History, Family, Social, Medications, Allergies when you're taking a history. You stand outside a cubicle, a buzzer rings, you read your handout, figure out which checklist you're going to need, memorise the patient's name, another buzzer rings and you're in.

You learn to introduce and consent in roughly ten seconds. Maybe 20 if you need to explain a more intimate exam. You're gently smiling, making the right amount of eye contact and trying to remember the first point of call on your checklist.

Checklists beget checklists beget checklists. Remember where you are. Comment on what you don't see. You can't be negatively marked so call out everything. Start at the hands, don't miss the capillary refill.

I sat in the one of my uni's many coffeeshops with my course buddy CRM and we listed 10 things to look for in the hands alone. Just call them out, you're bound to hit most of the ones you need for this specific exam. And anyway, in real life, you'd be looking for everything anyway, not just the finger clubbing of respiratory issues or the leuconychia of hepatic problems.

So back to my lecturers comment. when I turn up to uni before the exam, I sit on my adrenal response. Lots of revision of my checklists, not thinking about the exam. Drink me some coffee, try a little synthetic stimulant replacement. About 30 minutes before the exam, I imagine what it must feel like to stand at the door of a plane in the sky, about to do a parachute jump.

And Woosh

There it is.

At my word, unleash catecholamines.

Energy, alertness, fine tremor, my sympathetic response. My ancestors used this to run from wolves, I use this to stay focussed on a simulation of real life for 50 minutes. Which, incidentally, really doesn't feel that long when you're doing it.

But it's over for another year (god willing and I don't have resits).

I didn't have to revise anything today. It felt amazing.