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All in a day’s work

20 Oct, 16 | by Toby Hillman

24-hour-clock

Becoming a doctor is a long and arduous process.  It involves many years of study and more of practice.  It is inconceivable that this process leaves those who go through it untouched.  This process is called professional socialisation.  It confers values, and behaviours on the participants, and these help to mark our profession out from other groups in society.

The following reflection is from Dr Ciara Deall, a trainee plastic surgeon, recalling events which took place on a flight to North America, and in which her training allowed her to offer a stranger comfort, despite being off duty – a state that perhaps is never truly realised by those whose vocation is the practice of medicine.

We had cleared the west coast of Ireland and I was beginning to relax on flight AA365 heading for New York and a weeklong, intensive microsurgery course. Just time to let go of a non-stop week of on-call mayhem and enjoy some inflight entertainment to help wind down.

The intercom interrupted abruptly: “Hi, this is the chief steward, will any medically trained passengers please make themselves known to the crew; we have an emergency.” Almost without thinking I found myself standing up and telling a stewardess I was a doctor, before wondering what I might be letting myself in for – a stroke, anaphylaxis, heart attack, choking? Was I the only one?

The 19-year old girl was doubled up in agony, clutching her stomach, clearly very frightened and panicky. “Hi, I’m a doctor.” She was French and couldn’t understand much English. However, her GCS was 15, pulse and respiratory rate were raised but in range, she was not breathless and on eyeballing her from the aisle, she was in pain, but not acutely deteriorating.

The stewardess asked if there was anything I needed. “An interpreter please.” Not quite what she had been expecting, but after another intercom request, the perfect match was found and I made rapid progress in establishing my patient wasn’t pregnant, had no fevers, no urinary symptoms or diarrhoea, but had been out the night before eating too many different foods and drinking too much alcohol with subsequent vomiting episodes. Her pain was 4-5/10, crampy in nature and relieved by lying down. On abdominal examination she had very mild generalised tenderness, but a completely soft abdomen with no guarding or rigidity; bowel sounds present.

Her panic was subsiding fast with my apparent calmness as I completed the full history and examination. I was offered an astonishing state-of- the-art medical kit and pointing to an endless array of emergency drugs, including adrenaline, atropine and morphine, the stewardess invited me to help myself to whatever I wanted! I almost felt guilty in only using the sphygmomanometer and some mild pain relief, explaining the other drugs could severely harm or even kill her!

My patient settled to rest lying down, with water to hand for her dehydration. I promised to be back in 15 minutes. The crew were effusive in their gratitude and what it meant to them to have an ‘expert’ on hand. They recounted some past horror stories where no one had volunteered. Unwittingly I had calmed their nerves as well.

Back in my seat I reflected for a while on my encounter and realised the potential vulnerability of tens of thousands of long haul travellers daily and their attending cabin crew. Crossing immense oceans a truly sick person could be many hours away from trained medical staff and properly equipped facilities, unless there happened to be a willing, qualified passenger on board; clearly a gamble that is a daily occurrence. I was glad of my ATLS training, recognising it could be called on at anytime, anywhere, even at altitude.

Furthermore, it was a reminder of the unique (and privileged) position that doctors have, where particularly in emergency situations, complete strangers are willing to put their absolute trust in us. Even when we least expect it, the way we conduct ourselves and the skills we deploy can have a profound effect on those around us, for both patient and onlookers. No one cared whether I was a junior doctor or not. At 38000 feet I was valued for my willingness to offer and use my expertise. It was a sobering, almost humbling thought and without overstating it, I reminded myself that we are never completely ‘off duty’.

My patient slept. On waking she smiled feeling much improved and couldn’t thank me enough. Approaching New York, the stewardess asked if I had space in my carry-on for a bottle of their best champagne. I did!

At the end of the flight I accompanied my French charge off the plane. Another fascinating day in the life of a junior doctor.

The art of medicine.

14 Sep, 16 | by Toby Hillman

fountain-pens-1393977_640

 

Doctors have a long and proud history of involvement in the arts.  There are classic tomes published by doctors – The House of God (Shem), Sherlock Holmes (Conan Doyle), The Story of San Michele (Munthe), The Master and Margarita (Bulgakov).   The profession has also produced a number of playwrights (Chekov), and poets (Keats).

This exploration of the human condition through artistic expression is perhaps to be expected from a profession that is witness to human suffering, joy and grief on an almost daily basis. Reflective practice is a hotly debated aspect of medical training at the moment, with many trainees railing against the constrained forms of reflection permitted in official log-books and e-portfolios.

Dr Alice Ong of the University Hospitals of Coventry and Warwickshire submitted the following post, and joins a long a proud tradition of physicians who have turned to the arts to mark an aspect of their work.

Memories of Arnhem:

Looking after people when they are vulnerable is a great privilege of working in healthcare.  As a geriatrician, I consider holistic care very important, and find the lives of patients as interesting as their medical conditions. Over recent years we have lost those who saw active service during World War One, bringing World War Two veterans sharply into focus.

A recent gentleman was one of a handful who can remember anything about his time during World War Two. He and others of his age represent a different era, a generation of individuals who we will sadly lose as time passes. During a routine ward round, we talked about life. He informed me that he was with the 11th Battalion of the Parachute Regiment, and that he parachuted into Arnhem in 1943.

I asked if he had ever written anything about his experiences of this period. He would have liked to, but somehow he did not feel able. I looked into his eyes. I could see he was looking back into his memory box. I could see pain and anguish. A pair of eyes, that seemed to flick back to the past. Clearly he had seen horrendous things at a young age. His eyes came back to the present, and soon we were talking about his sore knee again. I decided to write this poem for him, and for those of his generation, as a final salute to a departing generation. Poetry was something I felt could best capture the reflection I could see in his eyes, whilst they flickered between past and present during our brief conversation. Although the past was behind him as distant echoes, the memories were still vividly in the present.

Arnhem, it was Arnhem.
We got the news, just not
Long before, the drop.
Us the 11 th Battalion.
Our turn, our turn.

Parachutes, many parachutes.
Were we lads, quite ready
To jump, guns poised?
Us the 11th Battalion.
Our turn, our turn.

Friends, many friends.
We lost many, in battle
Around Arnhem, years ago.
Us the 11th Battalion.
Our turn, our turn.

Memories, buried memories.
We were scared, but fought
So bravely, without fear.
Us the 11th Battalion.
Our turn, our turn.

Gunfire, sounds of gunfire.
We can see, the smoke
All around, of grenades.
Us the 11th Battalion.
Our turn, our turn.

Farewell, fondest farewell.
We are old, and lived
A life, friends missed.
Us the 11th Battalion.
Our turn, our turn.

Turning over a new leaf

5 May, 16 | by Toby Hillman

Decayed Aspen Leaf in B&W

Via Shaun Fisher on Flick CC by 2.0

 

The PMJ blog has been running for 2 and a half years, and in that time I have looked at many aspects of medical practice and education that have been thrown up by papers published in the PMJ.

As time has gone on, we have had several submissions to the journal which seem to fit better within the blog format than as ‘fillers’ within the published journal, but do not necessarily link directly to manuscripts that are due for publication.  However, they stand in their own right as pieces of interest to the PMJ readership, and cover experiences wider than my own.

As such, you will see different ‘voices’ within the blog, and I hope that these voices will also challenge and inform about subjects that have struck them as important in their clinical lives.  In contrast to the ever increasing enforcement of reflection in clinical practice, here are vignettes and observations that demonstrate reflection, but are submitted for wider circulation, and not hidden away on the servers of an eportfolio, or appraisal folder.

So over to Dr Welsby who has submitted the following ‘jaundiced view of jaundice’:

A confused young man and had been admitted with “?Hepatitis.” He was febrile and deeply jaundiced (patients with Hepatitis A or B, once jaundice is obvious, are usually afebrile and, barring complications, often feel better).

Obviously ”liver function tests” were in order. The first liver function test was to observe that his underwear was bile stained. The usual liver function tests were mandatory but predictable. His bilirubin was obviously high, too high to be caused by haemolysis alone (because haemolytic jaundice is lemon coloured and mild whereas obstructive or hepatitic jaundice tends to be deep and greenish). His ALT was moderately raised – unsurprising because his liver was tender on palpation and his alkaline phosphatase was raised in keeping with anatomical or physiological obstructive jaundice.

Obviously a clotting screen should be undertaken but what two tests that are rarely considered to be liver function tests should be performed. Firstly, the blood urea was high. This is unusual in hepatitis because the inflamed liver tends not to make urea (in formal hepatic failure the urea is characteristically low) and his raised urea suggested a degree of renal failure. Secondly, the glucose level (it is mostly liver glycogen that keeps up the blood glucose. In formal liver failure the glucose is characteristically low and intravenous glucose is often required. Hypoglycaemia is the only liver function test that can be immediately normalised.

One investigation that should not be omitted was the most important. A phone call to get a full history. He had recently been in Africa and his blood was full of falciparum malaria that would not have shown up on a routine blood count.

His parasitaemia demanded an exchange transfusion because parasitized red blood corpuscles cannot transport oxygen. Accordingly his blood was venesected and replaced by donated blood. Now, here is a question to which I have never received a sensible answer “How long does it take for stored blood, once administered, to start to transport oxygen?” Answers range between “a few hours” to “about 24 hours.” For stored blood duration of storage would obviously be relevant (someone should do an MD to investigate this). If he were given non-oxygen transporting blood there is a prospect of doing him a disservice by making him more hypoxic. This is why fresh blood is often used for such exchange transfusions.

 

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