Tuesday, 21 August 2007

The Nurse Has Landed

Ok first off. lets clear a few things up.........

Yes boys I am a real nurse living and working in "sunny" old Ireland, but, and there's always a but I'm a beer drinking, football loving, girl chasing MAN. Hopefully though none of you educated fellows assumed that "Two Weeks" would only consist of the type of nurses one see's late at night on Bravo.....

I work in very busy surgical unit in a large hospital, dealing mainly with issues of a urological nature, though we aren't limited to that really. Because of the nature of a lot of our work on the unit though, I've got a particular interest in mens health promotion and the lack thereof in this country. I've also developed a growing interest in the field of tissue viability and wound healing.

So thats the intro done.....

Hopefully I'll be bringing a bit of a different view to the blog and maybe help people see things a little differently. I'm hoping that my posts will range from more medically based to the more abstract issues in healthcare with a few mad things thrown in for free. Hopefully anyone who reads will enjoy my musings and please feel free to comment or critique.

Tuesday, 14 August 2007

The rage

Posted by Dr. Thunder:

So, that’s me back from holidays. No time to concern myself with slimey coins anymore. It's nose back firmly against the grindstone, with my least favourite pastime...the nightshift. Nothing breaks you down like being on nights in a hospital. Nothing erodes away at your ability to cope with day to day problems like being on the nightshift. Last night was no different.

When I arrived, I was told that our junior doctor was off sick with a vomiting bug. Fair enough. He's a good guy. He'd come in if he could. He's obviously pretty ill. So, I'll just plod on, and hope for the best.

It was a reasonably calm night, until James arrived in the door. He's a 12 year old boy with a history of bad asthma. Has been on a ventilator to keep him breathing during one of his attacks, and has been hospitalised numerous times.

Like many of these kids, he looked OK initially. We tried him on some nebulisers, which did the trick for a while. I also gave him some steroids. As time wore on, he was needing nebulisers more frequently, so I admitted him to the ward to observe him overnight. The nurses in our respiratory unit are superb. They kept a good eye on him, and called me at about 4am when James' breathing became more laboured.

At this point, I thought James needed Aminophylline. This is a drug that's given into a vein through a drip, and helps with breathing. It's a very good drug, but there are side effects, and the kids feel like crap when they're on it.

So, I popped a drip into his arm so the aminophylline could be started, did some blood tests, and I observed James for a bit. I was concerned he might need to go to the high dependency unit, or even intensive care, as he was beginning to struggle with his breathing. So, I stayed by his bed.

Then the pager goes off. It's one of the wards upstairs. "We have a septic baby up here, whose drip has come out. She's on intravenous fluids and her intravenous antibiotics are due". Why do these things always happen when you just can't leave your patient?!

Then.......brainwave. In our hospital, we have an "advanced practitioner night nurse co-ordinator". I don't know what that is. It's a lot of words, but I'm not really sure how they fit together.

Anyway, her job is to do her nurse co-ordination stuff around the hospital, and to perform "advanced roles". For this she gets paid more than the excellent nurses on the ward, who are helping me to look after James.

So, I asked the nurse who's phoned me to give the "Advanced practitioner night nurse co-ordinator" a bell to see if she could do it. "No probs, doc, I'll do it now". Happy days.

Or not.

5 minutes later I get paged back by the ward upstairs. "The advanced practitioner night nurse co-ordinator says she's busy". "Does she know what our situation is here?" I asked. "yep, but she says she's busy".

So, I rang her myself. I explained the situation. I explained I was about to phone the intensive care docs, as James wasn't getting any better. I explained that this drip that needed to be sited wasn't an immediate life or death issue, but it was important. I explained I was the only doc on for the whole hospital. "I'm sorry, but I'm busy". "Too busy to spend 10 minutes putting a drip into a baby with septicaemia, so she can have her antibiotics?". "yes". "Fine, goodbye".

Now, this person gets paid a lot of money to perform her "advanced roles". Yet, I have never met her, and I've been in the same hospital for almost 6 months! I have no idea what she does at night. I'm sure it's important work, in terms of co-ordinating nursing activity. But if she doesn't have time to perform her "advanced roles" then she shouldn't be taking the paycheque for it.

Which leads me on to the question I have asked myself and my colleagues many times.....Is the usefulness of any single member of the hospital staff inversely proportional to the number of words in their title?

Look at the people that we properly depend on in hospitals...."doctor", "nurse", "midwife", "porter", "receptionist", "physio", "security guard", "lab technician", "ward clerk", "occupational therapist". None of these people have more than 2 words in their title.

Then look at the people who are the greatest pains in the arses in hospitals. Look at how many words they get....."advanced practitioner night nurse co-ordinator", "Diabetes nurse specialist", "consultant physiotherapy practitioner ( I still have no feckin idea what he does, and I chat to him every day in our staffroom!) ". "Surgical services co-ordinator", "primary care paediatric pathway facilitator". I could go on.

Anyway, I digress. James went to the high dependency ward. He just about escaped the ventilator machine this time. I went up and put the drip into the septic baby myself, about 2 hours after it should have been done. It was difficult explaining the delay to her angry mum, but I've stopped trying to defend a crappy system. I just told her the truth. I told her I'd be writing an angry letter to the hospital manger. I wasn't lying. It's gone off in the internal mail this morning.

I feel like Robinson Crusoe this morning. I've started crossing off the days on my calender until I move to New Zealand. It can't be any worse over there than it is here......can it?

Thursday, 9 August 2007

The Roads of Ireland

Posted by Dr Indy

What comes into my mind again and again is the roads of this country and the untold amount of young lives lost on it.

Think of the 2 separate serious accidents in one small town of Buncrana in Donegal, think of the 5 lives lost in monaghan - and the two cars that struck were full of people going to the same wedding the next day.

Its horrific. Is it all speed or is it all alcohol and other drugs. Why do people do this to themselves, why do people think they can drive home in one piece every time they drink?

I was driving on the N2 one day - it was a clear day, sun descending at 8:30 at night. There was a touch of rain in the air that turned into a long shower later. I could see rainbows ahead behind the hills that the road gently wound through.

I turned a corner and saw wreckage strewn across the road - a car was perpendicular to the road and rubble strewn across it. I knew this was a serious accident and stopped the car and sprinted to the scene with my stethoscope and resuscitation mask in hand.

What faced me was a young fella, flat on his back and thrown a good 40 feet up from where his wrecked motorbike lay, stone dead. I tried desperately to resuscitate him on the roadside for 10 minutes before the ambulance crew arrived and then another 5 minutes before declaring him dead at the scene. Not once did he demonstrate any signs of life.

I was cut up for ages and angry with myself for not doing more. Gradually, I forgot about it and moved on.

Then I got summoned to the coroners inquest into the incident. All those memories of that dark, stormy night getting soaked by the roadside, surrounded by people crying came back to me. The dark days I spent afterwards questioning every step I made and what if I had brought more equipment? What if I had tried to intubate him? What if I ignored the fact his pupils were fixed right from the start and still insisted on giving atropine and taking him straight to the nearest A&E, 40 minutes away?

The inquest was a surreal experience. I met his family and they all thanked me for being there and trying to save him (this was not how I felt). I made my statement to the coroner and she used this as evidence that he suffered no pain as he was likely killed instantaneously. The pathologist report showed he had a fracture-separation of his spine and a completely ruptured aorta - the biggest vessel from the heart.

I got closure that day. I then finally realised that even if the accident had thrown him directly into the flashest A&E in ireland - he would have not survived. My roadside efforts were futile and nothing would have changed the result. I was beating myself for nothing.

But I also realised that I had forgotten my perspective. All I cared about was bringing this man back - I had lost myself in the plot. I blamed myself for something I could not change.

I was incredibly touched when the family spokesman stood up at the end of the inquest and expressly thanked me for being there that dark cold night. You ask, what if there was a doctor there - would things have been different? There was for him that night and the family took solace in this and I took solace in theirs.

Do what you want with lightbulbs and handtorches, but keep your money in your wallet!

Posted by: Dr. Thunder
I'm interested in public health. The spread of disease, and the wider cause of disease outbreaks fascinates me.
I also think too much.
I was in a shop the other day. While pulling some money out of my pocket to pay for my shopping, I noticed some "slime" on a shiny silver coin. Obviously, I scraped it off and passed it over to the nice man behind the counter. He was happy to take my hard earned money, regardless of it's condition.
On my way home, the slime popped back into my head. What was it? I don't think it was mine. I don't think I own any slime. I might, but if I do, I know nothing about it.
As I wandered down the road on the way to my house, new possibilities for the origin of the slime popped into my head. It started with pretty benign thoughts...could it be baby food? It might be hairgel, or even dried jelly...
10 minutes later, as my mind went into overdrive, I became certain it was something horrendous, like earwax..... or "manjuice"!
Regardless of what it was on my 5pence piece, it got me thinking.
Are there people out there who do "weird stuff" to money and then put it back into circulation.
I reckon that IF I were mad, I might be inclined to stick a few coins in me bum while I went for my evening stroll.
Or pop some coinage into my socks while I was in the gym. Imagine how funny it would be to put that money back into circulation....IF you were mad.
I'm on holiday at the monent, in the west of Ireland. The city I'm in right now has about 200,000 people. There must be a few people who do "bad stuff" with their money when they're at home. In fact, now that I think of it, a friend of mine once "made whoopee" to his missus while rolling in money, after they won a couple of thouasand pounds in the lottery.
I hope I never got one of his fivers.
When I did adult medicine, I sometimes saw people who had lightbulbs and hand-torches stuck up their bottom. No big deal to me. I don't have to use their lightbulbs after them, so never gave it a second thought.
But money......how many times does an individual coin or note change hands in a lifetime?
I need to stop thinking about this.
This is definitely a "holiday post" in blogging terms. Put in because I have no patients to speak of this week.
But, in true "two weeks on a trolley" style, we're raising an important public health issue.
Does anyone remember those ultraviolet lamps that were envogue a few years ago? Women, suspicious that their partners were being unfaithful, would shine them on their husbands' boxer shorts to search for signs of "manjuice". I propose that we should incorporate some of that technology into those anti-counterfeit scanners in shops. Any "sticky fivers" should be immediately sent back to the central bank for immediate destructioin....or they could be recycled into top-shelf magazines (don't say I never come up with solutions to the prioblems I encounter!)
As my holiday spending spree continues, I'll continue to be vigilant for signs of bum-hair and ear-wax in my wallet.
In the meantime, keep your coins out of your cacks!

Sunday, 5 August 2007

HIV lepers, and the culling of toddlers

Posted by Dr. Thunder:

I was doing a cheeky locum shift today. The NHS has made lots of junior doctors unemployed in the UK, in order to save money. This has resulted in there not being enough junior doctors left to staff hospitals. So they hire existing staff to work locum shifts, at extortionate rates. This makes it more expensive to staff the hospital at any given time than it was when there were more doctors. This is the National Health Service for you. You're best not to question it. Thinking about it can actually make you blind.

Anyway, I was in A+E seeing a toddler. He was pretty well. Very mild ear infection, but happy, smiling and alert. Feeding well.
I took a history and examined the child. Aside from his red eardrum, he had some unusual findings. Swollen, non-tender glands all over his body. His spleen was slightly enlarged. It could be argued that this may simply be part of a viral illness, but I was suspicious.
His dad had been an asylum seeker from Sub-saharan Africa. Mum was caucasian, born and bred locally. They met 3 years ago, got married quickly, and had a baby.

They had told me initially that they were both in good health. I asked again. "and you're both completely healthy?"..."Yes", they replied in unison."Neither of you have ANY medical conditions, then?". They glanced sideways at each other, and dad said "No". I don't know why I pushed it, but I did...."So, neither of you are on any medication?". Dad said "No". Mum hesitated, and said "well, actually, I'm on medication for HIV". Dad looked angrily at her. Not because he didn't know, but because they don't like telling people.

The three of us had a chat about it. Mum didn't get tested for HIV during her pregnancy. She had a normal delivery. She doesn't know if she was HIV positive when the baby was born. Her own consultant says she probably was. If she was, and it was known about, she would have had a caesarian section, and intravenous drugs during delivery. This would reduce the risk of passing the disease onto the baby from about 25% to 1% or less.

She had become seriously ill about a year ago, was admitted to hospital, and was diagnosed as being HIV positive. Dad also has the disease.

I told them that swollen glands and an enlarged spleen can be a sign of HIV. I told the child's parents that we should probably test him for the virus. They had been asked to bring the baby for tests after mum was diagnosed, but they never did. I spoke to the infectious diseases consultant, who happened to be in the hospital today. She kindly agreed to see them in clinic, for proper pre-test counselling, and we allowed them home until monday.

What struck me was that these people were willing to keep their HIV status a secret from the doctor who was treating their child. They must have known that he could also have the virus. But the stigma was greater than that. Think about that for a minute.Imagine having a disease, that you may have passed onto your child. But you feel you can't even tell the doctor who's looking after the little one, in case he judges you. I would like to think I don't judge people, regardless of their illness. But maybe I do. Maybe I touch them less. Maybe I take less blood tests than I do on the other kids. I don't know.

I'd also be interested in why people think there's still such a stigma surrounding this disease. I've known of children who were diagnosed in hospital, but have never told their GP. They sometimes don't allow the hospital doctors to write to their local surgery.

I understand people wanting to hide the diagnosis from their neighbours and work colleagues. Possibly even their family. But, why do people hide their most significant illness from those looking after their medical needs?

Maybe, as doctors, we're not as good at being non-judgmental as we'd like to think. Do we treat HIV positive people different to our other patients? Do we assume they're drug abusers? Do we make assumption about their sexuality? I don't know. I do know that this consultation will make me take a long look at how I act around these people.

I used to work in Africa, where people were sometimes literally disowned, or banished from their homes if they were found to have HIV. I have to say I've no idea what they go through over here. I always though we were more civilised than that. But in Africa, nobody was afraid to tell the doctor of their diagnosis.

Now that HIV has become more of a chronic illness, maybe things will change. On second thoughts, when I see how society treats those with other long-term illnesses, I'm not so sure. I do know that we can't expect affected patients to feel at ease in society if we can't make them feel at ease in our hospitals.

On a lighter note.......

I saw a kid today who was referred to me by a very sensible local GP. He thought the child had Henoch-schonlein purpura, which is a vascular condition that often presents with a rash on the legs.

Anyway, at first glance I thought he was right (he usually is). But on closer inspection, I started to have my doubts. This was, in fact, hand foot and mouth disease, although a slightty atypical presentation. I told mum. She started to cry. I wondered why, as she'd initally been convinced the rash meant her kid has meningitis. I thought she'd be relieved by the fact that her little boy had a self limiting viral infection of the skin.

"Will we be on the news?", she sobbed.

Ahhhhhh, I see what's happened here.

"are you thinking of foot and mouth disease?" I asked. "like the cows have in Surrey".

She was. I cleared up the matter, and we had a chuckle about it.

"No incinerator for you, Timmy*" I joked. Timmy loked up at me, confused, and continued chewing on our opthalmoscope.

All's well that ends well.

*As is always the case in this blog, I have used a false name.

Thursday, 2 August 2007



Ladies and gentlemen, today I bring you a warning. This piece of advice may (quite literally) save your ass.

I went to see a patient in A+E. 4 year old guy with a viral illness. I'd told him to take his top off and jump up on the examining trolley. Now, when I go to examine a kid's tummy, I very often do one of a few "set routines". Every paediatrician does this....I think! Usually when they're lying there, I'll look shocked and point to their belly button. Then I say "what is that?????, there's a hole in your tummy". Usually they have a giggle, tell me that I'm silly, and explain that "it's my belly buckkon".

Anyway, I started the routine for the 4th time in one morning. I looked my usual surprised and shocked self when I asked about this gaping hole in the middle of the boy's belly. His reply was given in hushed tones..."It's a button, but don't press it". "Oh right" says I, "What happens if I press it?". "me bum falls off" he replied, as both his parents went bright red and looked at their feet.

His parents had told him this when he was about 2 years old, apparently, to stop him picking at it, and he'd steadfastly avoided pressing his belly button since then. Sensible kid.

So there you have it. If you've ever wondered what belly buttons are for, now you know. You heard it here first.

This public service blog entry was brought to you by Dr. Thunder.

Wednesday, 1 August 2007

Is there something wrong with me?

Posted by: Dr. Thunder

It is in some ways ironic that the birth of this blog features a post that dwells on death.

I’ve spent a lot of time today asking myself if there is something wrong with me. I mean apart from the obvious! I’m talking about my abilities as a doctor. I tick most of the boxes.I think my clinical skills are reasonable. My theory is OK. I get on with the staff that I work with. But what I mean is do I react appropriately to emotive situations? Am I kind and sensitive enough to be a paediatrician? Am I the type of human being that people want near them in their most difficult hour?

Let me explain:

I was on the night-shift last night. I’m a junior paediatrician in a very large children’s emergency department in the UK. In the early hours of the morning the paramedic link-radio crackled into life at the nurses station. Ambulance control told us there was a crew enroute to the hospital with a 4 year old girl. “She has no pulse and she’s not breathing”.
A+E sprung into action in the way that it does. Drugs were prepared. Life support machines were cranked up. The intensive care team turned up. Even the surgeons popped in to see if they could help.
Nobody could help.
The long and short of it was that this beautiful little girl died long before she was brought into our department. It looks like she passed away in her sleep. We don’t know why yet. We tried our best to save her, but there was no hope. We gave her about 20minutes, without even a flicker of life.
As we gave up, the room was full of tears. It’s common after a paediatric death to see experienced staff crying. Everyone pulled it together as we called her parents and her older sister into the room.
Agonising, anguished howls filled the department as this poor family was torn to pieces by nature’s cruel hand. Looking helplessly down at your still, cold child is a situation I can’t even imagine being in.
When the commotion died down, and the family were sitting in the relatives room with the hospital priest, the A+E staff had their time to grieve. I walked into a darkened room, as doctors, nurses and auxiliaries all sat together. Nobody said anything. More than half of them were still crying. This isn’t a typical scene in an adult death, but it’s pretty common after an unexpected death of a child.

I don’t really work like that, though. I felt terribly sad for the family. My stomach churned when we called time on our resuscitation efforts. But I wasn’t upset in the way my colleagues were. I didn’t know the child, and I didn’t know her family. I spent about 15 minutes doing chest compressions on her, though. I was there in her final moments. But I wasn’t overly upset. I’m the one who went to see the next patient 5 minutes later, a toddler with an ear infection.

I’m not trying to be tough by saying any of the above. I’ll freely admit I cried when I lost my first adult patient as an intern, and I cried the first time I lost a baby at her delivery when I started paediatrics. I just wonder why I wasn’t upset, while grown men in our department shed tears. Why am I not affected like everyone else?

Some people say that when you stop being upset at a child’s death, then it’s time to leave paediatrics. Maybe this is true. Maybe I don’t have the emotional capabilities to do this job. Maybe we need people who can just get up and move on after tragedy. I don’t know. I’d be interested in the thoughts of others though.