Wednesday, 28 December 2011


Quote of the night from yesterday, by a father whose daughter had presented with a 3 day history of 4-5 loose stools a day and lower abdominal pain, on a background of being completely well and having one soft, formed stool a day:

"It's not constipation is it?"

Help me.

Saturday, 19 March 2011

Another hug

Thinking about the last hug made me think about a hug from long ago.

Some years ago, I was a surgical house officer working at a moderately-sized district general hospital. I was working the weekend. On Friday lunchtimes, the surgical teams all came together and had a big handover, where they'd discuss the patients they were concerned about and handover any weekend jobs. E, my colleague from another team, told me about Mrs V. Yep, I used to see adults as well. This one was quite small though, so I'm letting this post through on a technicality.

Mrs V had come in the prior weekend with large bowel obstruction. She had a distal stenosis in her colon, and the general opinion was that this was a cancer. She'd been for an endoscopy on the Monday and the consultant had managed to manoeuvre a stent past the blockage from underneath. This is a sprung tube, which can open up blocked passages. In surgical patients, these are a short-term measure; they release the pressure on the near side of the blockage temporarily, allowing the bowel to be more settled and thus easier to permanently repair.

However, the consultant was so delighted with this stent that he decided to sit on it all week, and ignore the warnings from the radiologists who kept doing follow-through tests to check its function that it was slipping and the opening was becoming narrower. E's handover wanted an early review for Mrs V, because if she was showing signs of re-obstructing, she would need to go to theatre sooner rather than later.

I saw her that night, and she was having diarrhoea - an early sign of obstruction (as the bowel is faced with a partial blockage, it works harder to push everything through it, meaning liquid stool moves through and reaches the outside faster - a concept known as overflow). I wrote quite clearly in the notes that this diarrhoea was not infective, and the patient should not be moved as they required an early review the next day.

I was called away from the ward round the next morning to attend an unwell patient elsewhere, and therefore did not realise the patient had not been seen, having been moved overnight to a side room elsewhere given the possibly infectious nature of her diarrhoea. The first I heard of this was at 12:30pm, when I strolled onto the orthopaedic ward to review a patient they were concerned about.

It was Mrs V. She looked dreadful. Tender abdomen, sweaty, pale. A quick blood gas revealed a lactate of 3.4 - not good. I thought she'd at least reobstructed, if not perforated. I order x-rays, bleeped my registrar and started some fluids.

The x-rays showed she had free air in her abdomen - she had perforated. The registrar wandered off to find a theatre. I repeated her blood gas - the lactate was now 6. Lactate, or lactic acid, is the stuff that builds up in your muscles and causes cramp when they're under anaerobic strain during exercise - it is a by-product of anaerobic respiration. Apart from a few rare metabolic disorders, a high lactate is usually a sign of poor perfusion; if insufficient oxygen is delivered to the tissues, more anaerobic respiration occurs, and the lactate rises. A rough rule of thumb; in severe sepsis, the lactate multiplied by 10 is your approximate mortality percentage. Not good.

I went back into the room, and Mrs V was weakly calling me over. She appeared to want to tell me something, so I moved closer, and she almost leapt off the bed and wrapped her arms around me, whispering in my ear, "thank you". She got progressively sicker whilst we waited for the orthopaedic team to finish - a 3 hour operation took them 5 hours 30 minutes, apparently for little other than the consultant's vanity - and by the time we got her into theatre, her entire gut was dead. She never woke from her anaesthetic.

When I'm dealing with very sick patients, I tend to make it fairly impersonal. It lets me think better and it stops me getting too attached. In this case, the hug ruined that for me. Mrs V stood out in my mind, because of that brief moment of human interaction. She still does.

Friday, 18 March 2011


Some people are unlucky enough to have to do the long day after the induction programme. Your first experience of a brand new way of working, and it's after hours. I had this experience recently. I had to get venous access and take pre-op bloods on an incredibly cute four year old who was having her tetralogy of Fallot repaired the next day. Cardiac kids have no veins. They're famous for it.

It doesn't stop you trying though. I aimed, I entered the skin with the needle, I probed, she cried, I hit something and got a little bit of flashback (blood brought into the end of the cannula through suction, to let you know you're in a vein), but couldn't advance it. She cried more. I took it out eventually, after she moaned and moaned and moaned that this was what she wanted, and held some gauze on her hand (which, of course, was now pouring with blood - they like to do that when you've been unable to get the cannula in).

I looked really sad at her. It wasn't a hard look to muster; I hate missing with cannulas, and I hate putting kids through unnecessary trauma. Evidently, this sad look was pretty convincing, as she looked at me, then launched herself forward off the bed and gave me this really big hug.

I'm lucky. I get to do some pretty amazing stuff at work. Sometimes, though, the thing that still makes you smile at the end of the day is the tiniest little thing like a spontaneous bit of comforting from somebody who has every right to be upset with you.

Saturday, 22 January 2011


It was my birthday yesterday, so I went out with a couple of friends and found myself in a slightly tipsy state, arriving home in the early hours. My rota has been a little busy of late - 17 shifts, seven of them 13 hours long, in 18 days - and with the weekend off, I fancied a nice lazy hungover Saturday, as advised by wise words from elsewhere.

Imagine my surprise when awoken at nine thirty by the sound of my telephone ringing. It was the consultant on call. The SHO for the weekend wasn't feeling well, and she asked me whether I could come in later on once I had sobered up and work a late shift.

I declined. I've been working hard, my sleep patterns aren't the healthiest at present for various reasons, and I've really been looking forward to this downtime. I think I need it. I told her that I was still drunk and I suspected I wouldn't be well enough to work later today.

It's now 4pm, and I feel a little fuzzy, but generally okay. I am following my original intention and having a lazy day. However, I can't fully enjoy the glory of doing nothing of note, because I'm feeling guilty. Work are short. They've asked me to come in. I've said no, and for good reason, but I can't help but feel like I'm letting them down.

Is this a situation unique to medicine? Do people with other jobs feel like this? Do I just need to get over the fact that I am not completely and uniquely essential to the running of the NHS?

Wednesday, 19 January 2011


This blogging thing is all a little new to me. It dawned on me that there are going to be groups of people that I write about with ill-disguised disgust, and I should really add some clarification to things.

Midwives in general have a reputation as being a bit of an odd bunch. The archetypal midwife is hated by basically everybody - nurses, obstetricians, anaesthetists, paediatricians, ODPs, partners, occasionally even the patients - and hates everybody in return.

Of course, there are reasons for this. They are independent, licensed practitioners, with legal responsibility for their patients. They work in a high-risk field, and have probably seen more horror and heartbreak than many people can even dream of. They have to be their patients' advocate (note the plural positioning of the apostrophe; they have at least two patients to consider in any clinical scenario), whether that means aggressively cajoling an exhausted labouring mother into finding reserves of energy she didn't know she had, or aggressively cajoling the sleepy obstetric registrar to come and cut a baby out.

In truth, most midwives I work with are lovely, lovely people. It might be because I'm a boy, can actually talk to people and didn't get hit too hard with the ugly stick, but it's rare that I have a personal problem with them. Professional issues can arise, particularly in areas our professions tend to disagree on - they would argue that better antenatal care and nutrition have been the main forces driving the perinatal mortality rate down over the last half a century or so, whilst we would argue that it is our aggressive attitude to potential neonatal sepsis - but by and large I have never run into a general problem with them as a whole.

Sadly, if you collect a big enough group of people, some of the group are going to be annoy you. Personal issues don't bother me so much, as I've long since accepted that there are some people who just won't like me. That's fine, it's allowed. It is issues surrounding professionalism that bother me, and from my personal point of view, specifically lack of regard for the baby. Some midwives seem to believe that they only have one patient, and the mother cares for the baby. This attitude leads to sick babies getting sicker and for fairly obvious reasons infuriates me.

The friends I have who happen to be midwives have long since understood that my bouts of ranting after experiencing midwifery-induced rage are not an attack on their profession as a whole. I have no kids of my own, but I imagine I will one day and I will quite happily let a lovely, competent team of midwifes deliver them in as natural a way as possible. Some of them piss me off. That's all.

Tuesday, 18 January 2011


A nice normal lovely Friday morning covering the postnatal ward. Our rota is balanced by giving us a week of half days when we cover postnates, which theoretically means we get to disappear at midday. We never do, obviously - far too busy up there - but it's a nice thought.

Six babies to check and two reviews. Nothing compared to busy hospitals, and although having less to do naturally slows one down, I'll be out of here on time.

One of the midwives potters over. "Oh, could you look at Baby C first, he's grunting."

Grunting in an infant is a sign of respiratory distress. Basically, in normal breathing, you relatively empty your chest, and then the inherent negative pressure in the chest inflates it again. It's why you struggle to breathe out when you're winded, because the muscles that do this for you have been stunned.

Babies with respiratory pathology can struggle with this. Newborns, particularly preterms, who don't produce enough surfactant, can struggle to inflate their lungs - they're "stiffer". Infants with infections can work harder and start to tire. Grunting helps with this; by breathing against a closed outlet at the end of expiration, you are maintaining the pressure in your chest and helping to keep the lungs slightly inflated. Think about blowing up a balloon - the hardest blow always comes first.

So, this baby was apparently grunting. I get told this a lot by the midwives, and the baby's absolutely fine. I was quite relaxed looking through the antenatal notes, as clearly they weren't too concerned if they were happy to wait for the routine day team to have a look at him.

I went to see the baby. He WAS grunting. He was also breathing fast. Hmmmm. I wheeled him through to the nursery where my equipment lives, popped him onto the resuscitaire, and also noticed he was recessing - he was breathing with such high pressures that he was sucking his skin into his chest, highlighting his rib cage more, as seen here.

Clearly, this baby wasn't right, but he didn't look too bad on balance. I asked one of the midwives to stay with him, took a blood gas from his heel, and popped to the gas machine on the neonatal unit it. I'd taken the postnatal notes with me, and noticed the night midwives had diligently documented how Baby C had been grunting when transferred up from labour ward, continued to grunt throughout the night, started having difficulty with his temperature, and they'd finally suggested at 7 hours of age that the day staff should perhaps get the paediatric doctor to review him this morning. Brilliant.

His blood gas - a quick measure of the gases in the bloodstream, along with other key chemicals that affect acidity of the blood - showed a respiratory acidosis. His breathing was poor, causing him to retain carbon dioxide, which was dissolving in the blood and causing it to turn more acidic. Generally, this is a bad thing. I advised the neonatal unit to expect an admission, sprinted back up the stairs, and transferred the baby down on oxygen, as he was looking a bit unwell by this point.

Chest x-ray showed a pneumothorax. Baby C was intubated and ventilated, had a chest drain inserted to drain the air pressing on his lung, and was transferred to a bigger hospital for ongoing care. Would this outcome have been any different if someone had called for help earlier? Who knows. Would I have been slightly less miffed? Yes. Would I have had a lovely relaxed Friday morning and afternoon? Definitely!

If a baby is grunting, get some help. The same rules apply for parents and midwives. Could somebody please tell the midwives?