Guilt

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?

Midwives

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.

Grunting

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?