Saturday, 13 April 2013

Guardian Angels

My Peri-Op Collapse weeks had me mainly based in ICU, apart from a seemingly unconnected trip to the urology wards on Friday.  I though t I would quite enjoy ICU.  The paediatric conference I went to in Brighton last year had featured a talk from a paediatric ICU consultant, and he'd made it sound really appealing and something I had been seriously considering.  Whilst I did enjoy me week, I don't think it is a specialty I can see myself doing as a full time career.  Plymouth is the second largest ICU in the country, beaten only by Birmingham Selly Oak, but the turnover in patients is the same, despite Birmingham having 4-5 times the number of beds.

The day starts with a ward round where a roaming computer and a team of Doctors goes from bed to bed discussing the patients progress with their designated nurse and amend any management plans as necessary.  Each patient is surrounded by a multitude of equipment - monitors, syringe drivers, dialysis machines etc, all hissing, beeping and blinking.  A nurse is responsible for watching over the patients, making a note of how their vitals change over the course of the day and this is fed back to the ward round.  For the majority of patients, this was fine, but I felt a little sorry for the ones who were awake, as twice a day a collection of people gather at the end of their bed, peer at them and discuss them from a distance, and then move on.  It didn't appear that they were included in the ward round, and it was mostly left to the nurse to explain if they felt it necessary.  I imagine it is bad enough to be that sick to be confined to an ICU bed, your friends and family kept from you apart from a few hours a day, being watched over constantly by a stranger, in some cases stripped of your voice by being intubated or having a tracheostomy, having no control over any aspect of your life and then to be peered at and discussed twice a day by more strangers that still don't talk to you.

I found it all pretty heartbreaking.  My patient I was allocated to had come in for a simple checkup in the liver clinic.  They have a condition that is currently baffling liver experts and so they come for regular tests to try and get to the bottom of it.  It looks like damage from fatty liver disease, except there's not enough fat in the liver to have caused it.  They came in with a bit of a cough and had to be persuaded to keep their appointment by their partner, as they felt too sick to go.  After the Consultant saw them in outpatients and some routine bloods were taken they were admitted for rehydration, treatment for community acquired pneumonia and then developed signs of organ failure and had to be sedated, intubated and admitted to ICU.  From having a bit of a cough to fighting for their life with their family crying around their bedside in the space of hours.

I spent hours by this patient's bedside.  I read their notes cover to cover, I knew everything about them medically, and had constructed the rest of the picture of what I thought they would be like around the medical facts I knew and insinuations gleaned from the language used by the various doctors they had seen in consultations.  I helped care for them, wash them, change their bed sheets, but what I really missed was being able to talk to my patient.  I admit it, I'm nosey, I love chatting to my patients, finding all about them, what makes them tick, how they got to be where they are.  Mr will tell you when we go to public places I'm forever eavesdropping, looking around, wondering how these people got to be in the same place as me under different circumstances.  I love people.  I couldn't work in ICU forever, although they are a fabulous group of guardian angels.  And if you were wondering, the last I heard, my patient had turned a corner and was getting better.

Thursday, 11 April 2013

Surgery loses its glamour

Week 2 was entitled 'Fever in the Post Op Patient'.  It started with a placement watching open heart surgery with an important Professor and Consultant.  Whilst I should have been amazed, as it was exactly the same operation as I had seen in the first pathway I found it a little difficult to muster the same enthusiasm.  I was quite surprised at this, as, don't get me wrong, I love what I do, but it wasn't new and exciting.  The placement is there because sometimes in the Major Elective Surgery week, the timetable works out that the students don't actually get to see any surgery, so the Consultant has tacked this by providing a session in this week.

I think it was also not quite so interesting, because over the course of my three weeks in Day Surgery, I had gotten used to playing a more active role in the theatres, and we weren't allowed to do that in this case.  It felt strange, as I even though I had the ability and experience to help, I hadn't proven myself to this theatre team and so was allocated just an observatory role.  The theatre team were lovely, getting me a stool to stand on and peer over the anaesthetic drapes into the chest cavity as I am a little on the short side and I was able to answer all the questions the surgeons posed me, even daring to have some opinions on things when that seemed appropriate.  But because we are only in places for a short amount of time we cannot be tested and proved worthy, so we cannot participate.

I had been thinking that I quite fancied the idea of surgery as a career, but I wonder if I would eventually get bored of performing the same surgeries over and over, as I had with just watching them.  Or, whether because I was taking an active role, surgery wouldn't lose it's magic.  I like the idea of the responsibility of being in charge to decide how to perform the surgery, the artistry involved with making incisions and dissecting through tissues and being able to fix things with my hands and be the one to make things better.

After a fantastic teaching session examining a patient with the Consultant, we were let loose on the wards to find our feedback patient for the week.  This was rather strange, as the objective was to find patients with complications following surgery, ideally, patients with infections.  It felt almost treacherous in a way, to be patrolling nurses' stations asking if there were any patients where things had gone wrong.  I know that things do go wrong and surgeons aren't gods, but it felt odd to assume that complications were so common place that we could go onto any ward and find a case straight away.  We aren't taught about complications, and our lecturers are all surgeons and doctors and revered, so the notion that they could have ever made a mistake or had a complication is unthinkable.  The notion is slammed in the media, it is drummed into us, complications are bad and should never happen, if one arises then mistakes have been made.  By the time I am an F1 (exam gods be willing) cardiac arrests will be 'never events' in a hospital, as in the signs should be monitored and actions taken before it can happen, with consequences should cardiac arrests take place in a hospital, which is a bizarre idea.  Happily however, it was quite difficult to find patients with post-op complications, and impossible to find ones with a fever.