Wednesday, 30 April 2008

A needle in giant haystacks

So, I've moved departments...again.

I'm now inhabiting the world of acute paediatrics. This is a world of snotty noses, red ears, high temperatures, and needle fear!!!

I hate needle fear. It's one of the big things you have to get used to when you start life as a paediatrician. In adults, taking blood is a routine procedure for most. Putting drips in means a bit of discomfort for the patient, but most cope with it fine.

With the kiddies, the opposite is the case. Some stoical characters just bite down and accept that you've gotta do what you've gotta do. But most of them, understandably, hate it. It's tough being a sick kid. I never had a drip, but I remember needing eyedrops as a nipper, and nearly tearing the house down in protest. So, I do feel their pain.

James was admitted from A+E this week. 8 years of age, with a bad tummy bug. Big strong 8 year old, so was only just barely requiring an admission to the ward. No real dramas. I thought he would be OK with some controlled oral rehydration, and an overnight stay. But my consultant wanted him on IV fluids. No worries.

James' mum is hyper-anxious. As a result, James is also extremely anxious generally. The thought of having a needle put in her son's arm made James' mum VERY anxious. This, in turn, made James VERY VERY anxious. This sets off a sequence of events that is replicated in paediatric departments the world over, and is intrinsic to the smooth running of the time-space continuum. It goes as follws:

I missed the cannula. Obviously. He jumped as soon as the needle touched his skin. The tiny nurse holding this giant's arm for me was no match for his startled reflexes, and the vein was destroyed. He screamed. This was a scream that only paediatricians and dogs can hear. It is a sound so high pitched that it has the potential to shatter stone. It is the sound that comes from all "treatment rooms" in paeds wards every day.

Mum started crying. Then she got angry. She started asking questions like "have you done this before?" and "are you going to get someone else to try?". There is always a look of shocked disbelief when you tell them you're going to try again. "AGAIN???" they shout? As if the need for intravenous fluids is dependent on your ability to get a cannula in first time. It is important to point out that this NEVER happens when the kid is tough, and accompanied by his even tougher granny. This only ever happens when you're putting a line into a "precious" child.

So, by now, both mother and child are in tears. They are both pissed with me. They both think I'm an idiot. I try again. Success. I remove the sharp bit of the cannula and throw it away. Just need to tape it into place now. James is still wriggling. The poor nurse is slowly losing this battle. I tell him the needle is out, and there's only a soft bit of plastic left in his arm. I tell him the worst is over, and he'll be back in his bed any minute. He doesn't believe me. Hell, his mum has seen me throw the needle away and she doesn't believe me. I am he-who-has-lost-our-trust, after all.

He's shaking. Convulsing. Trying desperately to get that drip out. Backup is summoned in the form of more large, stronger nurses. Too late. He's reached round and grabbed the drip and pulled it clean out.

The baby jesus cries at this point.

Mum looks at me, with red eyes of rage. I'm the culprit. It's true that i should have had more backup, but I never thought he was going to pull the cannula out while I was taping it into place.

So, at this point, all confidence in me is lost.

As always happens at this point, the consultant is strolling past. She's a friendly lady, so she pops her head in to see if everything is going OK. She sees the mess. The blood, the screaming child, the sobbing mother. The dimwit registrar.

So she offers to take over. I jumped at the chance to get away from a situation i've been in a few times before, but always fail to take control of, or to stop it getting out of control. So, the boss picks up the needle, and slides it effortlessly into a nice vein on James' arm.

Does he cry?? Does he hell. Does he try and pull it out?? Ditto. He smiles at her and says "That was much better than before".

So, all is well with the world. Another registrar has been made to look like a twat, without any damage to the patient. This is one of the main reasons that we are employed.

Interestingly, the procedure stressed James so much that he immediately demanded comfort food in the form of jelly and ice cream. Tolerated it beautifully.'ve guessed it. No need for IV fluids.

But at least the time space continuum was preserved for another day.

Saturday, 19 April 2008

Musings of the sleep deprived

POSTED BY Dr Thunder.

It's a short post this week, as I'm on night shift. That means I'm:

A) Too tired to blog properly

B) Too incoherent to blog properly

When you're on nights, things annoy you, way out of proportion to their importance in the grand scale of things.

For, example, the subject of my whineing on his paricular run of nights is the rather grandly named "lactation consultant" who visits our neonatal unit on occasion.

Now, I'm not sure what exactly a "lactation consultant" does. I know she wears a power suit and talks to mums about breast feeding. I'm not 100% sure why we need her. She looks expensive. From what I can work out, she's a nurse who has some extra training in breasfeeding. So she's there to pass her wisdom onto our new mums. Our excellent nurses in NICU talk to our mums about breastfeeding too. They don't call themselves "Looking after sick baby consultants". I suspect she earns a lot more than them, too. She is, of course, unavailable out of hours.

Anyway, it's not the lack of a freely available job description that has me riled. It's the rubbish that she writes in the notes. Why is it that anyone with the title "consultant" in their job title* thinks the whole world is interested in every minute detail of their "Client episode"? The reason I'm saying this is because our lactation consultant has seen 3 mums today. In each case she has written in the notes "I have empathised with (patronisingly insert the patient's first name, which she uses without asking if that's OK) regarding her sick baby".

I mean who writes that they have empathised with the parent of a sick child?? There is probably an "empathy pathway". There may even be an empathy facilitator, who could be called in for a referral.

*sadly, the exception here are my medical consultants. About half of them never write in the patient notes. They expect the resident (junior doctor) to document their decisions. This is becoming more widespread in my opinion, and I find it very unprofessional. For all the faults in the UK service, our neonatal consultants used to see every patient every day, and write a full plan for every patient every day. Here , in about 50% of cases, the ward round consists of a consultant asking the registrar a few questions, telling us what he wants to do, while the poor junior tries to transcribe his/her ramblings. Your decisions.....your far as I'm concerned.

The final thing that's been pissing me off is getting the blame for stuff that ain't your fault. EVERY doc has been in this boat.

This week the senior registrar came to review a very sick patient that I was looking after. He changed the kid's intravenous fluid regime. Sadly, he didn't bother to write up a new fluid order. The nurses are pretty good when we're busy and are usually happy to take verbal orders, within reason. So, the boss noticed on the ward round that the new fluids hadn't been written up, and proceeds to tear me a new arsehole.

I didn't even know the fluid regime had been changed!!!!

I assumed I'd made some kind of a cock up, so I just toook the abuse. I am absoloutely 100% against the idea of ANYONE in the hospital environment (or in any environment) raising their voice to another member of staff, regardless of the circumstances. It's, essentially, illegal, and rightly so. But sometimes you've got to take it.

The senior reg was in no hurry to offer up the fact that it was his cockup.

Then the next day I was on the morning ward round after the night shift. I basically tell the day staff what has happened to all the kiddies overnight, just before I go home. As I was discussing a baby, one of our nastier consultants asked me "has this kid has her MRI yet?".

"No, she hasn't".

" rant rant rant rant blah blah blah this is totally unacceptable Dr. Thunder blah blah blah" basically ripping into me. This is becoming a recurring theme.

Now, I'm just the night shift guy. The day to day routine management of this patient isn't my responsibility. That's the responsibility of the daytime team. At night we are running on minimum staff, so we only deal with acute problems that arise. We're not expected to do the routine work. It's just too busy for that to be an option.

I explained this as best I could. It's unit policy, so surely he'd understand?.....

His response.......

"Blah blah blah it' unacceptable Dr Thunder blah blah blah completely unacceptable".

Jesus christ.

The actual team who were looking after him stood beside me in silence. Wouldn't want those references being compromised, would we.

Why are hospitals full of people like this? Answers on a postcard please......

Sunday, 13 April 2008

Rough day at the office

Posted by Dr. Thunder

What a horrible day today was. We have, coincidentally, 2 babies in ICU at the moment who have both suffered possible brain damage at birth. Both had their MRI scans and EEGs this morning, and the reports were with me by late afternoon.

Both babies had abnormalities on their MRI and their EEG. So, our team had to go and speak to both sets of parents in turn. It took about 3 hours in total, and was horrible.One of the problems (when I say "problem", I mean in the sense of giving information) is that both these kids could well be fine. They may well have no poblems at all. But they may suffer seizures, learning difficulties, or visual impairment at some point in the future. So, basically, it's a case of talking to the parents and telling them that, because the extent of the damage is difficult to assess accurately, we can only say that their child may run into problems. We can't give percentages, or even ball park figures. Basically, keep watching them until they go to school! I mean, how stressful is it to face into that! 6 years of being on edge all the time.

These were 2 very upset sets of parents. But, to their credit, they were very understanding about what info we could give, and what questions we simply couldn't answer.I always feel crap after these types of conversations. But it goes with the territory, I guess.

On the keep sane, i always convince myself that, in the world of neonatology at least, there's a ying and yang effect. For every bad thing that happens to me, a good thing happens. So, just as I was leaving work, the emergency buzzer went off in theatre. They were doing an emergency caesarian section. Our excellent, but very inexperienced, resident was there for paediatric input. The baby came out purple, and she very sensibly pressed the emergency buzzer, and assessed the baby.The baby wasn't breathing, and had a heart rate of only about 20. The resident tried to initiate bag+mask ventilations, but couldn't seem to get air into the baby's lungs (ie she was pushing air through the baby's mask, but his chest wall wasn't moving).

I arrived in, she explained the story as I was putting on my gloves. Baby was only 50 seconds old at this stage. I readjusted the airway, started bag+mask breaths, and thankfully the chest started to move. The heart-rate came up. Baby became pink, and started breathing himself. Happy days. It's not as difficult a task as it might sound, it's just scary! But, at the end of it we have a totally well baby, who will stay with us in NICU for a couple of days of IV antibiotics, and a chest x-ray, just in case. But no harm done. I've said it before, sometimes medicine can be the best job in the world. Sometimes it's the worst. Some days it's both!

Thanks for listening.

Wednesday, 9 April 2008

Now.........I'm not gay..........BUT...........

posted by : Ain't No Angel

Look look..........another post..............2 in 2 days, your getting spoiled!!!

This is totally non medical related but I'm so full of happyness and joy and excitement that I felt I had to tell you all, and detail the reason why.

Its quite simple really, and its all caused by one man. You may not be aware but I am actually a bloke nurse. I'm also not gay and happily on my way to marriage later this year to Mrs Ain't No Angel, ('ve got 6 months!). I am a simple man, who takes pleasure from simple things like beer, music, building random things with power tools and sports. I've never really entretained thoughts about other men...........until now..........because I think I'm in love..........with a man.

And this man is...............

This modest unassuming young man has been a revelation since signing for Liverpool, and has been a bright star in the fairly grey skys around the city.
I'm not the only one to be having this problem either. Men up and down the country are having this crisis. Many of us didn't even feel this way about people like Keegan or Dalglish. Its a starange feeling but one I'm more than happy to run with, especially if this blonde bombshelllgets us past Chelsea to the Champions League final of dreams against Man Utd. If that happens and we beat them......I'll love it, I'll love it if we beat them!

Tuesday, 8 April 2008

Thats fighting talk girly!

Posted by Ain't No Angel
special mention to Dr Ellie

This post I'm going to discuss the discussion that has come up around my last post. In case some of you didn't know you can add comments after each and every post that the 2weeks team put up here on the interweb.
Following my lastest coffee/nicoteine fuelled rant, a disgruntled Doc has been furiously posting comments and generally venting her spleen on some of the topics I've been mentioning.
Now, this silly doc thinks I might be mad at her.........when in fact nothing could be further from the truth! In fact Ellie, your a kindred soul. I admired what you wrote, it took a bit of balls, (i'm working in urology so maybe I'll get that checked for you), and using some of what you wrote I'm going to add my bit in and maybe we'll come up with something resembling where I'd like nursing to be in a few years time.
Que copious quoting and plagiarism......

I'm an Irish doc who left due to the crap conditions and working hours in
Ireland. I'm currently working in New Zealand, which treats docs pretty well,
and our hours are extremely humane.

Btw, I certainly don't mean to direct this at you! You sound like a really nice
nurse, and the fact that you even KNOW about our working hours, let alone
care, says so much. Most nurses at home were not aware that we were forced
to be on for 36 hours straight and didn't believe us or care if we mentioned

As any regular reader will know I've mentioned this before, and it gets on my you know whats so much. NZ has a rough population of 4,264,871,very similar to Ireland, so we'll assume that it has a roughly equivalent tax take. Using this as a basis, then how come they can run their system without working their Dr's to death? Maybe, what we should do here is totally dismantle all the health service machinery and rebuild it in the image of NZ or another good example? Oh wait...........thats what the HSE idea was about.....whoops!

Nurses here, if a patient complains of chest pain, do an ECG, give GTN,
do a set of obs, and call you unless the patient is clearly crashing. If
they suspect a patient is in retention, they do a post mict bladder scan.
Many take bloods and site IVs, and only call you when they don't get them in. They take verbal orders for meds. They give first dose IVs-that's a BIG one that's always annoyed me intensely. In Ireland, many times nurses would go so far as to make us give the first dose of say, IV Augmentin, even if the patient had already had it on this admission, and we were just restarting him on it.

Thankfully giving first dose antibiotics has more or less gone in most hospitals, most of the time we happily give them with few problems. I'd really only start thinking about not giving something if I was really unfamiliar with it. Most times though, a quick call the the pharmacy dept is the best line, as to be fair, most Docs don't know much about the routes of all the mad scary type drugs anyways! I agree though, that first dose stuff was nonsense of the highest order in all but a very very few cases.

When I was a student, I worked in A&E on a placement for 6 weeks. Standard practice there for nurses to do ECG's, well in the dept I worked in. By the end of the 6 weeks, I was doing the things in my sleep. Now, as a fully qualified registered nurse....... I'm NOT ALLOWED do them..... for those not in the know, ECG's are pretty simple to carry out, in fact apart from Dr's the people who do them most as ECG Technicians, I'm not sure what qualifications they have, but I'd assume its not a PhD. Point is, its not that difficult.

Taking blood is another one. Nurses in general don't do this. There are exceptions alright, but for the main part they don't and aren't trained to do it. Even if I went on the course.......the hospitals won't let me do it, or put in a cannula. In fact, if I did do it, and it got out, I'd probably be disciplined. (BEHAVE!)

This all seems a bit silly doesn't it? But see it relates back to some of the things that I was saying before....

See, if i start taking bloods and putting in cannulas, then I'll end up doing them all, and I'll never get a Dr to do any of them. This takes time, so how am I going to get the time to fill in all the care plans, reports and ticky box bits and pieces of paper that I'm already snowed under with? I'll still have patient ringing the call bell when they need a hand in the toilet, I'll still have patients to help get washed in the morning, or to make sure that your granny eats her dinner. See where I'm going here?

There's no one really below the nurses that can take on the jobs so that we can take on a few of the extra Dr ones. Yep, there are the healthcare assistants being trained up as we speak, but until they actually create a proper job spec for these people, and sort out the area of delegation and the responsibility of the nurses for the HCA's practice, they are going to sit on the shelf and it'll all be another waste of time.

While I've no desire to become a "mini - doctor" I'd certainly feel that it'd make more sense to have nurses performing quite a few of the roles that the NCHD's are now doing. Unlike the private sector though, the public health system doesn't seem to much a fan of innovation, free thinking or change. Until, that realisation hits home, nothing will change, at least to a degree where things for patients and staff will get better.

Just a final point...........Ellie.......I always try to be nice to the Doc's. We are after all on the same side. Sure, I've let rip at a few of the pompous fools but I've made friends with plenty of your lot. The behaviour shown to you though as a female NCHD was a disgrace though, and on behalf of the muppet nurses that were like that......I'll apologise. It happens though, especially if your at least vaguely pretty, make an effort with your appearance or are a bit outgoing. Its jealousy i think, but who knows........just between you and me though, I'm always nicer to the girls than the lads........dammit.....Mrs Ain't No Angel is looking shhhhhhhhhhhhh don't tell her!

Saturday, 5 April 2008

The week in review

Posted by Dr.Thunder

So, it's been just over a week since I started my new job, and so far so good. The people I work with are friendly, and the hours haven't been too onerous.

I guess my main problem is one that many docs will identify with in a new environment. It's the lack of trust that I sometimes face. I'm reasonably experienced in neonatology, and would regard myself as reasonably good at the job. I'm not perfect, but I can do enough to get by.

So, it's a bit frustrating when I outline a management decision to the nurses, and they just run it by one of the other registrars "just to make sure". Some of these registrars are more junior than me, which makes it doubly frustrating. I'm all for teamwork, and I have to admit spending alot of my time asking 2nd opinions from the other docs, because things are often done very differently here in Oz. But when ever decision you make is questioned, it gets a bit tiresome.

I was in theatre the other day for a "high risk" delivery. We go to these deliveries to resucitate the baby if the need arises. Usually ourselves and the obstetricians co-exist peacefully. But today's on-call obstetrician doesn't like new faces. I walked into theatre and started preparing the resus equipment for the impending caesarian section. He walked right up to me and, without introducing himself, said "I don't want a resident here. I want a registar for this delivery". I told him that I was the registrar, to which he replied "I said I don't want a resident, I want a reg".


After I convinced him to let me stay he said "You know this baby is going to the nursery with you, don't you?".

"Well, let's see how the kiddy is. It might be fine, in which case we'll just leave him or her with mum".

This sparked a big argument. He was adamant that this baby should be admitted for observation, regardless of it's condition. I said I wasn't admitting a well baby. He said "Look, I know you're only new here, and you don't know how we do things. But this baby is getting admitted to the noeonatal unit".

I agreed, just so he would hurry up and get this baby out of it's bleeding mother. So, a few minutes later, one completely well baby came into this world. I gave him back to his mum and tried to escape back to NICU, as the obstetrician sutured a uterus, or whatever it is they do.

But I was too slow for his eagle eye. He noticed, without even looking up from the ovaries in front of him, that this deviant paediatrician was trying to leave babyless. The argument flared up again. As far as I was concerned, he doesn't have admitting rights to scarce neonatal beds.

I wasn't trying to be unhepful. I probably admit more babies for observation than I need to. But I'm really very strongly againt the idea of splitting up a mother and her baby straight after a traumatic delivery.

I told him he could call me if the baby showed any signs of being ill. Nope. Not good enough. "I want a consultant opinion", he said. Ok.

"Hi, neonatal consultant on-call. It's Dr. Thunder, your new registrar. I've just been at an emergency c-section for a maternal bleed. They were worried about the baby in utero, but he's totally fine. No resus required. I've given him back to his mum. But Dr Obstetrics wants to observe him in NICU. I've told him it's not neccesary, but he wants a consultant decision".

This is where the 2nd tier of distrust comes into play...

"He can't possibly want an admission for that reason. You must be missing another issue".

Oh sweet jesus.

"No, I'm not. I clarified this with him. The one and only issue is the maternal bleed".

"OK, don't admit the kid. It's not need to be careful about over admitting. Dr. Thunder. You don't want to seperate mum and baby early on unless you have to. That's not how we do things here".


So, i went back and explained the situation to a disgruntled obstetrician, who mumbled something about crap neonatal care.

I was glad to get back to the neonatal unit. Back to familiar territory, where I could make decisions about head circumferences, neonatal lung disease and such other familar topics, without a fully formed uterus in sight. Even if those decisions do get run by my more junior colleagues "Just in case".

Thursday, 3 April 2008

What's Goin On!

Posted by : Ain't No Angel

Sitting here on a week off from work following a week of night duty I can get pretty bored. There's me, the cat, Dr Phil and the xbox. Good friends to a man (or cat), but they don't compare to how unbored I generally am at work. Things are usually quite frantic there, eventhough we have a well run shop. Its gotten me thinkin though about what I be doing from one end of the day to the next, and what kind of things it is that seem to keep me so occupied.

So today, I'm thinking that I'm going to share with you all the things that keep me busy in work, along with a little of my thoughts on each.

(This may take a while, its going to be one of those stream of consiousness type posts.....)

1) Patients

Well Duh , I hear you say, and you'd be right. Its primarily the reason I go to work everyday, and most of the time its the patients that make my job so cool, rewarding and interesting. Sure, it'd be great if it was like ICU and they all were asleep all the time, but then I'd miss the banter, the craic and all the good stuff. I'd also miss the tears, the anger and frustration and all the little things.

2) Dealing with Dr's

We're normally not to bad at this. Because we're pretty specialised we have our own teams and everyone gets to know each other pretty well. There is generally someone from the team on the ward all the time, so getting things done is rarely a problem. Things start to go wrong when you are dealing with Dr's from teams that have patients all over the hospital. Even something simple like getting laxatives charted can be a nightmare and take hours. Why? Well sometimes, its because said Dr is a fool/lazy/badly organised, but 99% of the time its simply because they are so so so busy running around the place trying to be all things to all men that they simply can't get to you.

I've posted about how I hate how our NCHD's are treated in this country, particularly interns so I'm not going down that road/rant again, but in this day and age, you'd think someone would come up with a solution that meant Dr's wouldn't have to work for 2 days straight with about 4 hours sleep in-between, if they're lucky.....

3) Bureaucracy

Now I know everyone, no matter what job has this issue, and in Ireland the HSE has rightly gotten stick for the increasing bulk of admin workers it employs, so lets not beat that horse again. I'm talking about the nonsense I have to deal with directly, not the people in the ivory towers of HSE/DOH-land.

For a start, despite the amount of worthless admin we have, there simply aren't enough ward/doctor/general secretaries around. Our own ward clerk is a legend. Highly organised and intelligent, she can sort out a multitude of things for you but she's a minority. I've worked with loads, who are useless. When she's not around, getting a patients old medical notes from storage can become a Hurculean task, up there with peace in the Middle East.


Because there's no-one in the records dept free to get it and bring it up.

Never mind that though, what about the litany of paperwork that have to sign, tick or otherwise file on a daily basis on every patient I meet. Add to this mix, meetings, radioographers and their nonsense from time to time, plus the additional hassle of dealing with HR from time to time, porters and finally cleaners (who won't clean or who aren't allowed to clean certain things or areas).

It can all get pretty painful sometimes!