Palpitations and Gunner Bean

Week 2 was palpitations and when I spoke to you last I said it hadn't been as exciting as the first chest pain week.  There was a trip to MAU, followed by what was supposed to be a cardiac catheter placement.  It turned out that had been cancelled because of a scheduled monthly departmental meeting.  It was a run through of all the statistics of the department for the previous month - how many operations, how many bed days used, how many complications, who was the most active surgeon, reg and anaesthetist and what barriers stopped patients from going home.  Then there was a mortality meeting where they go through who died in the last month and why they died.  It was interesting in a way, because I didn't know they did such things.  It was a bit brutal for the surgeons seeing all their stats up on the board for all to see and they were getting quite defensive with excuses like how their surgeries were generally harder and longer which is why they hadn't done as many.  I guess it sort of promotes competition within the team so they are all trying to be better... or faster, which probably wouldn't be a good thing if that made them make mistakes.

The medical school are doing a similar thing with us.  We have an electronic log book where we have to log all the patients we see, what histories, examinations and skills we did on them, what was wrong with them and what we learnt from them.  You can see your totals on a graph so you can see how many you are doing.  We are supposed to be aiming for 3-5 a week.  Also plotted on the graph are lines for the range of patients seen by 10-90% of the rest of the year and 0-100% of the year.  In theory, you can therefore see where you are doing against the majority of the class.  What it actually does is promote the feeling of 'I must be the best!!!!'  I don't want to be top, but I do aim for top 10% every week.  It's not possible every week, as sometimes the opportunities just don't come up to see patients.  There is also the inevitable moment where you finish logging for the week and think your top and then log in a little later to see everyone else just hadn't completed their logs yet so you're in a completely different place.  There are some people who still haven't logged any.  I hope they have good notes because I would never be able to remember if I didn't write them up that week.

Thursday afternoon of this placement week we were sent on a bit of a wild goose chase around the hospital. We were sent to find the office of a Consultant who had actually retired over summer.  Then we were told to go to his clinic, which hadn't been taken on by anyone else so wasn't taking place.  Finally we were sent to the cardiac catheter lab staff room to wait for a different consultant.  It was three hours before we actually started our placement, and it would have been the same as the Tuesday placement had that not been cancelled because of the meeting.  Pretty poor planning on the medical school's behalf.  After an absolute grilling by the consultant he lead us on a tour seeing exciting things.  On one cath lab table was a patient who was in multi organ failure and had arrested three times on the way down tot he procedure.  Everyone was on tenterhooks waiting to see if they would arrest again.  It was pretty much a last ditch attempt for them, and there was a bit of controversy as to whether they should have even been attempting the procedure in the first place as it wasn't likely to work.  Apparently the mother had been distraught and begged them to do something, so they decided to give it a shot.  We left half way through so I have no idea if it worked and the patient survived or not.  On another table they had just completed laser ablation of an accessory pathway in the heart and were all on their phones killing time waiting to see if the pathway would open up again once it settled down.  That was bit surreal.

Next comes the really exciting bit that I feel so guilty for.  My partner had seen a cardioversion the previous week but I had missed it as it was after a feedback session and I had to run to the Ladies Dinner Night.  The procedure is to shock the heart out of an unstable rhythm and into a more stable one, in this case atrial fibrillation into sinus rhythm.  It's not a lifesaving operation as you can survive in AF, just with a higher risk of developing blood clots, so you tend to be put on warfarin.  Quite a few older patients spend their time flicking in and out of AF, as it can spontaneously resolve.  In that case however, the patient was fairly young and fit and it was bothering them, so the consultant decided to cardiovert them out of it.  My partner had almost gotten to push the button but an F1 poked her head around the door at the last minute so the consultant gave it to her to do instead.  It is quite exciting; it's a different use for the 'charging, stand clear, shocking' defibrillator machines you see on the telly, just they don't use paddles any more  it's electrodes, wires and a button.

Because he had nearly gotten to do one, the consultant we were with had promised him that he would be able to do it this time.  It was explained to us that the person we were about to see was a private patient of the consultant and was fairly wealthy and important and had paid to be cardioverted out of AF as he had slipped back into it again.  The longer you are in AF, the harder it is to get you out of it and you are more likely to convert back into it again, so this wasn't a definite fix of a procedure.  As we entered the curtains the patient was put to sleep and the consultant turned to me and told me to dial up the right charge, push the sync button, say stand clear and push the shock button.  I blinked at him and he ushered me forward to hurry up while the patient was sleeping as it wouldn't last long.  Me.  Not my partner.  I am ashamed to say I leapt at the chance.  The gunner in me came out and I couldn't turn down the opportunity to do something cool.  But I feel so guilty about it!  My partner was really looking forward to it and.... ARGH!  I'm not that sort of person usually, I don't know what came over me.  But it was cool though :-D

We were ushered away quite quickly once it was clear he wasn't going to flip back to AF and then sent to look at a slide show on how to read ECG's.  It occurred to me after that I'm really not sure I had consent to do that procedure.  It was a private patient that I didn't even speak to and I'm pretty certain he didn't even register we were in the cubicle.  I'm going to blame the slinky green dress I was wearing for the fact the consultant gave it to me not my partner.  It's a professional dress, not low cut and appropriate, but slinky nevertheless.  I made a mental note to be sure to put my partner forward for the next cool thing we got offered the chance to do.