work

That conversation.

My first rotation in my newly chosen specialty (Geriatric Medicine) is on a ward with a policy of not-for-resuscitation.  I really hate that term.  It’s so loaded, so weighted with the implication that we’d just give up.  The context of this current job is that my patient’s have such severe dementia that they’ve forgotten their families, how to use a fork, tie their shoelaces.  If they were to die from natural causes, say a heart attack, our policy is that we should not attempt to restart their heart, or put them on machines that breathe for them, for the simple fact that it wouldn’t cure their heart problem (there is no cure for old age), certainly not cure their dementia, and cause a lot of pain and suffering for an outcome that at best, would give them a few more, horribly painful days of life.  The alternative is if that something catastrophic were to happen, instead of doing things that would achieve nothing but pain and suffering, we would change our goals to prioritising comfort and dignity.

I am at the start of a conversation that will define my career, and one that as a society we are in the process of defining.  I am loathe to go into the mechanics of what happens in these situations.  They’re traumatic enough for trained personnel.  In the movies and television, there’s about a 70% success rate if you get CPR or shocked with the paddles, or go into ICU on a breathing machine.  In reality, it’s about 20%.  If you’re young.  If you’re over the age of 80, it’s close to, if not 0%.  And yet so conditioned by the media are we, that we hold onto the hope that our loved one will be the magic one, the one that proved the doctors wrong.

So even when I have the discussion with the family members of the patient with advanced dementia, a barely functioning heart, and that near-0% success rate, they still tell me to ‘do everything’, to save their loved one.  But I can’t.  I can’t save them.  You can’t cure ageing (yet) and you can’t cure dying of old age.  Sometimes I’m successful in explaining these principles.  The principles of goals of care, of ‘doing everything’ for anything we can absolutely cure, for not ‘doing nothing’ when we can’t.  We never do nothing.  One of my favourite professors once told me that as doctors sometimes we use medicine and surgery to treat problems, sometimes we use morphine and ice-cream.  The opposite of ‘do everything’ is not ‘do nothing’.  It’s ‘do something else’.

Which brings me to ‘comfort and dignity’.  What does that even mean?  I say it a lot at work, because it’s a goal that resonates.  The mechanics of comfort and dignity is that if Something Bad happens, instead of trying to fix the unfixeable in desperation and poor judgment, we fix the symptoms instead.  If the Something Bad causes pain, we give pain relief.  If it causes distress, we give relaxing medication (similar to Valium), if there are other symptoms, there are things we can do.  The end result of going through that sliding door instead of the other, is a loved one, peaceful in bed, in no pain, and sometimes able to talk to their loved ones in their last hours-to-days.  This is in stark contrast to the CPR/breathing machine situation.  Stark contrast.

I want to be clear that this is not euthanasia.  Euthanasia is a complete can of worms which at this point in time is a dogs-breakfast that I don’t wish to visit.  But symptom-relief and subsequent dignity I’m a big fan.  It doesn’t hasten or bring on death, the underlying disease does that all by itself.  But it does make the path there a lot less traumatic for the patient and their loved ones.

I’m so far down the rabbit hole of medicine these days that sometimes I forget that I’m using jargon.  It’s hard to know if I’m losing my patients families when I have this discussion because 99% of the time they’re so polite.  And yes, it’s my job.  There’s a form I have to fill in with a families plan for their loved ones passing.  I don’t want that to come across when I have that conversation.  I’d love to hear some reader’s experiences of death and what was done well and what wasn’t.  This is a conversation I’m going to have a million times over for the rest of my carer and I want to get it right.

 

Reasons why I am late sometimes.

I was on Facebook the other day and watching a bunch of people complain about their doctor being late.  I started wondering about all the things that made me late to see patients so I thought I’d write them down in the hope it would make everyone in the SMH comments section hate doctors a bit less.  Possibly more if they see this but hopefully not

Reasons why doctors I am late sometimes.

  1.  I have lots and lots of patients.  This one seems obvious but in a hospital you can never see a new patient quickly.  It comes back to bite you if you do.  And most of the patients in hospital are of an older vintage and can’t be expected to remember the bits of their medical history I want them to remember so I have to ring their GP, their other hospitals, and their kids and their neighbours to piece together enough of a history that helps me understand why they’ve come to the emergency department unconscious, and what of their medical history is likely to slow them down getting home.
  2. Figuring out what medication my patients are on.  I know this should be in 1 but it deserves it’s whole own category.  Working this out is a bit like India Jones with those Roman numerals in The Last Crusade sometimes.  The amount of medications that some people are on and who has changed them and when is mind boggling.
  3. I am hiding in the toilet from the boss that was really mean to me a year ago and I don’t want him to see me and be mean to me again and I have to text my intern and find out if he’s gone even though he probably has no idea who I am but he might.
  4. I need a coffee and have in fact slowed to a standstill while my panicked intern runs downstairs and comes back and puts a coffee in my hand so I can drink it and we can keep moving.  Also I’m not allowed to drink my coffee on the ward/in front of you so I have to finish it before I keep moving or hide it in convenient places where it can’t hurt anyone.
  5. I am eating lunch.  We get half an hour for lunch.  I take 9 minutes exactly with an extra 2 minutes staring into space/groaning about having to stand up again.  It still counts as a delay because I could be seeing patients in that time.
  6. I already came to see you but you were asleep/getting a test/told me to piss off.  I always come back!
  7. I am chasing a delirious person.  This a common and unseen job of hospital doctors/nurses/cleaners/security/random hallway guy.  Delirious people have no idea where they are or how they got there so it’s only natural they would try to leave, and only natural they would get very upset, nay violent, when it is suggested to them that they can’t leave.  Chasing a delirious person means walking after them, but not too close, trying to join them in whatever delirious place they’re in and trying to reason with them into returning to that strange bed with the strange other people in the other 3 beds in the room because it’s good for their health.  No, I wouldn’t believe me either.
  8. Ranting at the ward clerk because my patient keeps calling me nurse.  I have been seeing them daily, every day, for two weeks and introducing myself as their doctor and it. does. not. compute.  So then I inevitably rant at the sympathetic ward clerk about #everydaysexism before my intern comes out and tells me the orthopaedic surgeon is here to have a chat about our patient and ask which guy he is in the group over there.  Naturally, it’s a woman.  This rant always makes me late but it needs to be had.
  9. I am hungry and my blood sugar is -5 and there are no patient biscuits in the cupboard so I have to go upstairs to the vending machine and eat something delicious but disgusting so I can make the words English good.
  10. I am blogging.  Haha just kidding, I wish.  Hospitals have the strictest firewalls ever.  They even block reputable medical websites.  But curiously not Youtube.

And while I’m procrastinating…

Did I really not post since last September? Let me catch you up on the last year:

  • I started physician training.  (For those not familiar with the system, when you finish your internship and residency, you often then thinking about the pathway you want to do: surgery/physician training/obstetrics/general practice/anaesthetics and so on.  Physician training is what you do to become a medical specialist something, don’t ask me what yet!)
  • I spent six months at The Regional Hospital From Hell.  It wasn’t all that bad, but it was really really hard.  Like, you pick up the phone 24 hours a day for 7 days a week, every three weeks, for four hospitals spanning a large country region.  And you deal with questions like, chopper or ambulance?  And you keep your cool when people call you at 3am for a medical issue not even remotely related to your specialty because they don’t want to wake up the right person who is known to not keep their cool and figure since you’re so junior, you’ll just say yes.  You come into work for all seven of those days too.  The sleep deprivation was a bitch.  As was seeing my husband once a week (when I wasn’t on call).
  • Lots of my hair fell out from the stress and I discovered a bald patch! I have the best hairdresser ever though, and it all grew back.
  • I made some new friends in my new network, and started working at my new home hospital which is great! I found a lovely study group…now to just err, study (more).
  • I stopped being vegan because it was too hard, I realised that the population examined in Forks Over Knives (i.e. I’m not an overweight type 2 diabetic who required bypass surgery) and there’s some great evidence for The Mediterranean Diet.  So rather than treat myself for something I don’t have, I switched over to preventing something that I may easily develop.

In short, life has been boring for a blog, but exciting for me.  Interesting election huh?  I wasn’t surprised by Tony Abbott winning it, and I got a sausage AND a cake at my local voting station.  What have you been up to?

Conversations in strange places

It’s 7pm. I’ve hung around at work well past finishing because I have a dinner date nearby and I’ve just finished up in critical care. My friend whose on until 11pm and I are sitting at the nurses station talking about life and science fiction, future plans. In the background monitors are alarming, sounds I hear as I fall asleep at night now, ringing in my ears, reminding me that medicine never sleeps.

My friend is brilliant. So keen is he to become an ICU specialist, that he has taken responsibilities far beyond the rest of us, and been rewarded with skills and knowledge that far outstrip my own. He’s waxing lyrical about laterally thinking your way through a nosebleed in a bleeder (a sick patient prone to bleeding too much), I’m having one my regular crises of confidence, the uncomfortable result of being part of a specific minority in med school that all too slowly is disappearing Right in the middle of my crisis of future failures he lands it on me.

‘Make your worst performance the best on the day’. My fugue is broken – and he explains that as the result of being forced to do high-level music for his entire life (that he says is specific to his cultural heritage), he had to take nerve racking performance exams yearly. For his whole life. That he met with prospective failure, and sometimes the reality, so often that he learned this valuable lesson. His father explained that the more you practice, the more our bring up your own worst performance, that if on the day you choke, you drown in anxiety, that even if you give your worst performance, it will be the best performance for the day.

It was one of those moments in life where you feel your mind undergo a massive correction, that ‘aha! I understand what I need to do now!’ moment. Where self doubt evaporates and is replaced with motivation and interest. Your baggage can cloud a lot for you.

In the background, a new patient is wheeled in, intubated, an unfortunate survivor of a horrific accident. More alarms. One of the nurses asks another if they want Chinese takeaway for dinner. One of the seniors wanders past and reminds my friend that a new patient has arrived, does he want to put in some lines?

We say our goodbyes, I thank him, and as he walks away he says, ‘us good people have to stick together you know’.

I swell up with pride to be counted among his own.

My Ecology

You died. You bloody died! You weren’t supposed to die. You were supposed to be the part of the story where I learn the true magic of modern medicine, the Saving Lives dream come true. But you died.

My history of you begins with the bat phone. It’s really called that. Loud important noises go off, the two way radio gets picked up, the story begins. An electronically transmitted ECG appears on the screen. It’s bad. It’s real bad. My registrar tells me to go to the resus bay and I busy myself setting up stuff to put a line in and get blood. Needles, tubes, alcohol wipes. And then you’re there on a stretcher, eyes wide open, scared. You’re barely moving. You’re talking two words at a time. People are everywhere, fussing with breathing gear, setting up for an ECG, attaching you to monitors. The boss is shouting orders. I shout back that I’ll get a line in. My reg leans in and says “are you sure can do it fast?”. I nod yes. It’s automatic. Immediately I doubt myself, I’ve only tried one line this large before and it was such a horrible painful failure that I never tried again. But this time it’s different. The line goes in immediately.

We push in fluids, the cardiology team arrives, time for you to go upstairs. Upstairs. The magic life saving place that is the cath lab, where truly broken hearts get fixed and where you’re supposed to live. You’re only young. Your wife and daughter appear as you’re being wheeled away. The boss stops the bed moving for a minute so they can have a moment. An eternal moment. I watch from a distance as your wife sinks into a chair and your teenage daughter stands there blankly. And then you’re wheeled away. Wow, I think. Wow. To be a cardiologist must be so amazing, because they’re going to fix that.

We go back to our other patients. Five minutes later the sound of emergency pagers ring out, reaching a collective crescendo. The team leader nurse is already halfway out the door with the portable defibrillator. She shouts at the medical student, the only one free to push the cart. He’s only just started on clinical rotations None of us doctors can help, we’re too busy with the other patients. I watch him obediently follow her up stairs.

We go back to work. Later the team leader appears. “He arrested. He’s tubed now. They’re pushing on with the angio”. Everyone agrees to find out what happened in the morning, it’s time to go home, now past midnight.

I’m at work today. I have a few patients I’m sorting out, mainly elderly people with elderly person problems. I see the cardiology registrar. I ask him. The registrar shrugs and says “oh that guy died”, and walks off.

You weren’t supposed to die.

I go back to work. The wind is out of my sails. For a minute a small voice tells me I want to cry. Another tells me it’s not my journey. Another tells me to get back to work which sounds sensible so I do. Another says nothing and just observes.

“You’ve got to learn to be more lazy”. I look up, and an intern is standing there, handing me a coffee. It’s late. It’s nearly time to go home. “you’ve seen so many patients” she says, “way too many!”

She’s right in a way. I’m not getting out on time. There’s a lot of paperwork left to do but I don’t really mind. I used to mind. I stay back and finish it. I lament my lack of thoroughness for seeing so many. I call consultants to get the patients admitted and give half baked stories but it’s late and they just want to sleep so they accept them.

I get my handbag and walk back to my car. Driving home I notice the other cars on the highway, some big, some small. Lights passing through the night.

You weren’t supposed to die.

It’s the little things

This rotation I’m working 11 hour shifts. On your feet, no holds barred workworkwork 11 hour shifts. The boss cracks the whip, tells us to go faster, get people through, I swear some days I wonder if the apocalypse is here – it might as well be a scene from Outbreak out there.

It doesn’t leave much room for anything. Not much reading time, I don’t want to even contemplate exercise – just enough time to eat some food and collapse on the couch or bed, whatever’s closest. No one gives a crap about how healthy or unhealthy their doctor is. They just want to get fixed and go the hell home. Me too!

So you find small, stupid ways to live a life around it. You buy a gift box of chocolates and eat the whole box and it’s GREAT and you do so with no guilt because you’ve worked your ass off all day. And not at a computer, literally not sat all day, constantly moved around for 12. hours. Your feet feel like crazy angry people who scream at you and your back is like a prison.

Hot baths. A chocolate bar at lunch time. A roll of eyes shared between residents. The nurses finding a chair without you even asking and commanding you sit down or you’ll stuff up your back like they did theirs. You feel like a cross between a mechanic and a waitress. More chocolate. The boss saying good job. The Internet, bless the Internet which provides hours of immovable entertainment. The people on the Internet. Your blogs.

You stop sweating the small stuff. Daily slap becomes a bit of powder and a brow pencil. If you’re more awake maybe some gloss. Eating shit because the smallest of scrubs hide ALL sins. You stop worrying about being fat/thin/pretty/ugly/smart/stupid/too much/too little. It doesn’t really matter. It doesn’t really matter when a crazy guy has just shit in the waiting room or someone has a cardiac arrest in the way back from the toilet. It really really doesn’t matter. You just want to eat the chocolate, read the Internet and hope you’re not too tired for a run on the weekend, you cross your fingers that you’re moving enough to counter the bad food behaviour. You don’t care about getting fat, you fear glycemic toxicity, cardiovascular disease, impaired immunity.

But mostly you appreciate the little things. Most people blur into one. The nice ones stick out. You forget about the rest. You love chocolate and baths and chairs and the Internet and a kind word. Your family, scented anything, acts of kindness from yourself or otherwise.

The rest just does not matter.

Love.

Lately I’m on a work-clothes buying craze, which in some ways is pointless when you’re dealing with sick people because there’s always something that’s going to get spilt on you.  Like projectile vomit on my favourite pink cardigan.  Blood on my shoes.  Abdominal proteinaceous fluid on pants in spite of wearing a gown.  I could go on, but for your sake I wont.  In spite of this, I continue to buy myself nice stuff because a lot of the time, my job isn’t nice.  You’ve got to find ways to take the edge off.

So first I bought these:

Pour La Victoire Bre Flats

I’m having a huge thing for Pour La Victoire at the moment, the sizing is small but they’re so well made.  These look fabulous with everything.

I’m a huge menswear fan, with flashes of girliness from time to time but at work it’s all business.

Bop Basics Boyfriend Shirt

I admit, I bought it entirely for the sleeves.  I love them!  Anyone know where to find some ultra low-slung workpants I can tuck this into?

And I don’t mind a little bit of lace either – but just a little.

Club Monaco Clara Shirt

I think this one’s going to be a staple.  I have no idea who Club Monaco are but they make some nice stuff.  And I probably shouldn’t be buying silk in my job, but you only live once.

And what do you do when you think the Equipment Signature Blouse is just way too much money?  You buy a Madewell one instead.

Madewell Charlotte shirt

That should keep me out of trouble at work for a while!