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The Daily Rhino
Tuesday, June 26, 2007

Someday you realise your Mum's not going to live forever
Originally published in the June issue of Medical Student Newspaper.

MY first year is drawing to a close. The next generation of F1s have graduated, got pissed and are enjoying that golden summer after medschool. Soon I will no longer be the most junior doc on the team and I might even have people asking for my advice. Every time I mess something up (and I will) after the end of July, I won’t be able to simply excuse myself on the grounds I am “just the house officer”.

Part of the exercise in group stupidity that is our MMC assessments is a tedious cataloguing of ‘reflective practice’. We are supposed to document the cock-ups, the near-misses and blips that we have learnt from. Of course I spent half an hour before my sign-off meeting making mine up.

Ironically, writing this column has forced me to reflect on my conduct as a doctor more than any contrived questionnaire could. I spent a little while browsing what I have written for Medical Student Newspaper this year and I realise I have come full circle. The first piece I wrote, in October last year, professed how I need to see things through the eyes of patients’ family members. I didn’t change. Nine months on, tragic events have finally shocked me into an attitude re-evaluation.

One of the many criticisms one could level at me is cockiness. I have been gung-ho on more than one occasion. Whilst I have not endangered patients, I have certainly made more work for myself by charging ahead without due forethought – and more importantly I could have made a patient’s stay less unpleasant.

I write this having just returned from Royal Free’s ITU. My very best mate’s Mum suddenly suffered a massive antero-lateral MI and out-of-hospital VF arrest. He’s a school friend and a lawyer, she’s a healthy woman in her mid-40s with no risk factors apart from family history. Without going into details, she has been making erratic but slow progress over the last two weeks and we are optimistic.

I’ve tried to be as supportive as I could be, but I’ve also done my utmost to explain the immensely complex events to my friend. I hope I helped. However, in a roundabout way, I have helped myself.

I’ve been privileged enough this year to get exposed to a high level of critical care. I’ve managed patients in coronary care and in surgical HDU. Next year I’ll be working in medical HDU and ITU. I love it – standing behind the chart, absorbing the figures.

Heart rate, pulmonary capillary wedge pressure, MAP, fluid balance, CVP, inotropic support, balloon pump settings, sats, lactate, base excess, ejection fraction and so on. I got a buzz out of being able to know what was happening with the patient without even seeing their face.

Suddenly one of those collections of stats was someone I knew. I finally put a face to the figures. More than that, I put a face to the relatives that spend their whole day in the waiting room, desperately hanging on for a glimmer of hope. I became one of them for a time.

When you’re looking after a full HDU, something is always happening. When you’re concentrating on only one patient, nothing seems to happen. Our days consisted of sitting silently in the waiting room, walking around the block, nipping out for cigarettes and if we were very lucky, perhaps a minute with the SpR.

There’s a vast difference between nursing staff. Some are rude, obstructive and lie. They claim the doctors are far too busy to speak to relatives. When I’ve been on call, I’ve positively approved of this attitude. Now on the other side, I realise little is more frustrating. Other nurses are great and really keep relatives in the loop. Likewise, some doctors are jerks. Others are absolutely fantastic.

In a less acute setting it can be even worse. My Mum has also spent some time in hospital recently. In contrast to my friend’s mother, this was a planned admission for a knee replacement. Straightforward, but the potential for complications always exists. And whilst not life-threatening, my Mum suffered badly with wound and chest infections and terrible post-op analgesia.

She had to wait four hours for a doctor to write up pain relief. The nurses would mindlessly repeat “we’ve bleeped him” and when he eventually arrived, he dismissed everything I said, presumably because he thought I was too junior.

This pattern of waiting for the doctor was played out daily, perhaps part of a scheme to free up hospital beds, as after a few days my Mum was desperate to leave.

So much of the modern medical apprenticeship appears twee and pointless. Hoops to be jumped through, like the aforementioned reflective practice essays, or apparent time-wasting like communication skills classes at medical school. I was as vocal as anyone with my criticism of what medicine is becoming. I echoed consultants who bemoaned the demise of ‘the old system’ of being taught the science and picking the rest up by osmosis.

Now I wonder if I should have attended more of those communication skills sessions. When I say “more”, I really mean “at least one”.

Textbooks have taught me what I need to know about managing a GI bleed or a sore knee. What textbook could I turn to when I first told a family their father had died? I have broken this news about half a dozen times this year. I am not happy with how any of them went.

Sure, you live and learn, but I look at some of my colleagues and cannot help feeling that they were just born with a better ability at this sort of thing. I think one can learn to communicate better, I have just never felt it to be a priority. For it is a paradox in life that whilst we are more conscious of our shortcomings than our strengths, we spend less time rectifying our foibles than doing what we’re good at.

Hence this year I have consciously pursued an agenda to improve my practical abilities. I’ve taken out an appendix, intubated, cardioverted, lumbar punctured, put in about ten chest and ascitic drains, four femoral lines, two arterial lines, one temporary pacing wire and aspirated more chests and knees than I care to remember. The one procedure I have been especially keen to master has been the internal jugular central line. I have managed to do six, with supervision, simply by being a pest and keeping my eyes open.

Conversely I have avoided interacting with patients and families for the vast majority of the time. I make excuses to myself that my jobs have all been too busy, but I seem to have made time for all of the above. My development has been uneven.

Last week an acutely unwell woman came in to the MAU. There was talk in the air of a central line being needed. The on-call SpR had not had time overnight. Aha! My opportunity. Number seven here we come. “I’ll get everything ready” I said as I practically forced the team into accepting me as the man for the job.

The woman began to deteriorate. I was already preparing to insert the line when her breathing became erratic. “Rohin, don’t worry, you go ahead but we need to get this line in quite quickly,” said one of the registrars present. I looked down and saw quite a young woman. I saw my friend’s Mum. I saw my Mum.

In an acute and unpredictable setting like this, would my running a catheter by this woman’s lung and into her right atrium really be the best we can offer her? I desperately wanted to get another central line under my belt, but I stepped back. “I think you should do this one,” I said to the reg, “I’ll watch you this time.”

Perhaps I am learning something.

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Your post reminded me of Atul Gawande's "Better", which I've just started reading. It seems great, and since you seem to be a doctor-writer yourself, you might enjoy it.
That's interesting - I've literally just started reading Complications, his first book. I'll check out Better if Complications gets the thumbs up! Cheers.
Complications was ok, I didn't find it too earthshaking, but it certainly had interesting bits to it. I felt it was light enough that I did justice to it listening to it as an audiobook, instead of sitting down and reading it. Better seems more promising.

The thing that grips me about his writing, though, is his humility and honesty about himself. Even in spite of his inclination to play hangman on anesthetized patients' surgical gowns.
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