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The Daily Rhino
Friday, July 11, 2008

Real Doctor
Originally published in the June issue of Medical Student Newspaper.

THE very first plasty I wrote after graduating was entitled 'Pretend Doctor'. So it seems rather fitting that my last column as a foundation doctor (the first two years of training) carries the title of 'Real Doctor'. It has taken me two years before I felt ready to describe myself this way, but after last weekend I realised my two F-years have taught me more than I realised.

Some months I have to struggle to find something to write about. Other months it is immediately apparent. I didn't even have to think about the subject matter for my final column as I recently experienced one of the most memorable few days I suspect I will ever work through.

I am currently working in ITU and thoroughly enjoying it. I have been looking forward to this job all year and am considering it as a career choice, but it has only recently dawned on me how ITU is as much about death as it is about saving lives.



During my last weekend on-call, our unit had five deaths within about sixteen hours. None were unexpected, but all were quietly heartbreaking. Two stood out and taught me skills I know I'll find useful throughout my career. The first case was that of a 27 year-old man I shall call Stephen. Stephen had been in the unit for the best part of three weeks. He was admitted with a severe pneumococcal pneumonia on the background of pulmonary sarcoid. Over the days he had developed horrific ARDS with multiple broncho-pleural fistulae and bilateral pneumothoraces.

He was critically unwell for the majority of his stay, dramatically hypoxaemic and hypercapnic, before entering multi-organ failure. By the weekend I was on-call, he had four large-bore chest drains in his chest and quite astonishing surgical emphysema all over his body, puffing his face up like a beachball.

Stephen also had an amazing family. His siblings and parents took shifts to keep him company (only two visitors are allowed at a time) and made sure his favourite records were always spinning in his room. He had an enviable soul music collection, with Marvin Gaye, Stevie Wonder, Smokey Robinson and Billie Holliday constantly vying for attention with the sound of Stephen's high-frequency oscillatory ventilator.

His family were understanding, grateful, calm, realistic, loving and clearly brought closer together by the slow deterioration of their son and brother.

On Saturday chest drains numbers five and six were inserted to attempt to further re-inflate his lungs. He now had three drains in each hemithorax. All six were on suction and bubbling furiously away.

About half an hour before I finished my shift, Stephen's nurse called me in a panic. One of the new drains had stopped bubbling after draining some blood. I realised the tube had a big clot in it and tried to unblock it. This proved somewhat tricky as the clot extended along the entire length of the tube. As I asked for a bladder syringe Stephen's blood pressure started dropping. His systolic fell from 90 to 60 in less than a minute.

Marvin Gaye provided the backing music.

With metaraminol in one hand and the bladder syringe in the other, I nervously kept his BP propped up. I thought this is
probably the kind of thing my SpR should know about, but she was speaking to another patient's family. They were in tears, asking her to pull the plug on their loved one, yet she had to rush out midway.

Before she arrived Stephen went into PEA arrest and I started chest compressions. A cycle or two into CPR, Stephen still had no output. I was sure the chest drain was the problem but unblocking it was not easy. Suddenly an idea hit me, one that was both a product of following simple guidelines and attempting to diagnose the problem.

It was Stephen's 28th birthday. Meanwhile, Al Green was singing.



I pulled an orange cannula out of the crash trolley and plunged it deep into Stephen's left chest. A whoosh of air was followed by a recordable blood pressure and a pulse. I'd done it. A tension pneumothorax is such a film and TV cliché but for obvious reasons, it's as dramatic as hell.

I wanted to be the one to talk to Stephen's family. I am not sure why, was it anticipating the kudos I would receive after telling them of my actions? Or was it simply because I had developed a relationship with them and wanted to be involved? They were, as always, quite remarkable. They seemed genuinely concerned with thanking Stephen's nurse and me. Whatever bravado I had felt melted away as I realised that despite my proud moment, Stephen was in the same position he was in half an hour before.

By the time Stephen died, aged twenty eight and one day, within a day of this tumultuous episode, he had seven drains in his chest. A final blow was dealt when the transplant team, requested by his family, opened Stephen to find not a single viable organ.

Another death at the weekend was that of an old friend, a 70 year-old I will name John. I say old friend because I had known John for eight months. I met him in A&E and got to know him and his family during my four renal months, during which he was an inpatient for the entire duration. John had a past medical history as long as your arm and what I thought was the family from hell.

The entire renal team was wary of them. They were abusive, demanding, unfair and sometimes malicious. In fact I wrote about them once before because they drove me up the wall. John paid me a visit in ITU; his fourth admission there.

I warned colleagues: "be careful with that family" but soon realised that it was the renal ward they had trouble with, not any individuals, as they were perfectly friendly to me in ITU and indeed sought me out as someone to talk to as I was a familiar face. John became very sick very fast and suddenly I found myself in the breaking bad news mindset. Once again I took close family into the 'relatives' room' to suggest he had only hours remaining.

From the first time I met John he was bed-bound and withdrawn, but I learnt he was once a proud patriarch of a huge extended family. His two daughters and his wife remained by his side as the months had gone by and whilst I would once have ducked into the doctors' office to avoid a confrontation, now I saw three women losing the man of their house. I was overcome with guilt. I should never have let myself dislike these people.

John's wife, who had become quite motherly to me over the weeks and months, surprised me. She leapt up to hug me and said "I'm so glad it was you." I can assure you I wouldn't be glad if I was my doctor but I think one recognisable face in the bustle of ITU was reassuring.

Later I was with another patient and my SpR came over in floods of tears.

"What's wrong?"
"It's John, his whole family's there and it's just so sad. They're asking for you."

I nervously parted the curtains around his bed and found about twenty people crying, holding hands, saying prayers. It was clear that John commanded utter respect from those around him. It would have been nice to know him as his former self.

His wife brought me right into the middle of the throng and I felt like a complete imposter. Did they know how I used to feel about them? She told me that I always treated John like more than just a patient, that she would be sad she wouldn't see me again and that I will always be in her prayers.

I definitely did not deserve this. The feeling of guilt at receiving praise I was unworthy of, combined with the real happiness that I had made something of a connection with this family was unusual. I am sure I won't forget what John's wife said to me, perhaps even more so because of our colourful previous dynamic.

Corny or not, I can honestly say I will remember this weekend as a seminal point in my career. The moment I realised I am a doctor that can save a life - albeit only postponing death for a day - and that can make an emotional connection with a patient's family.

In the nicest possible sense, I hope you all experience an occasion in your career where you are forced to exceed what you thought were your limitations. When I finally got a day off several days later, I was exhausted and drained, but I had never felt more positive about my job. These are the experiences that teach you more than any DOP or CbD ever could.

After four fantastic years editing and writing
Medical Student Newspaper, I can finally switch my bleep off. Good luck.

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