there is a lot more to being a medical registrar than looking after patients. actually, when i think about it, thats usually the easiest part of my job. most patients have relatively straightforward problems: exacerbation of a chronic illness; some sort of infection; social issues; or simply being old and having less physiological reserve. it's really a matter of triaging, writing up the drug chart or making a referral to allied health, and seeing what happens.
what i find to be most challenging is actually having to manage people. striking a balance between leading and learning from my consultants; supervising my residents to make sure they are safe, yet giving them a degree of independence to learn how to think for themselves; teaching the students while trying to study myself.
lots of my friends and colleagues are thrilled to be registrars, and hate the idea of doing resident jobs, the mundane tasks of rewriting drug charts and putting in iv cannulas, and the lack of freedom to make treatment decisions. well, i dont mind the mindless tasks - i find them quite satisfying, actually - and i find that i have a great deal of influence on my patients' inpatient experience even if i dont get the final say on how their medical problems are treated. on top of all that, being a resident is far less stressful than being a registrar! so, yeah, i am looking forward to being a resident again when i return to melbourne...
26.6.10
13.6.10
tyranny of distance, part 2
the diabetes educator had left her the previous day after a 2 hour "catch-up", apparently well except for ongoing unstable bsl (which had been going on for years). she found her in the same position 24 hours later, unconscious, gcs 11 and febrile. with no obvious explanation for her temperature of 39.5 (impressive for a 82 year old), mild neutrophilia and a surprisingly normal crp, i asked the ed resident to do a lumbar puncture. id just done a question on herpes encephalitis and aciclovir was on my mind. sure enough, the csf came back with high proteins, relatively normal glucose and (drum roll please...) 100% mononuclear cells. and so the aciclovir went in. the next day we noticed she was having seizures and added phenytoin. her gcs fluctuated between 6 and 8. things looked bad.
her closest family was her dead husbands nephew 110kms away. he was the only one that seemed to care (i will try to come up doc but it wont be until the weekend cause im working) but didnt feel comfortable making medical decisions for her. there was a son in wa, he said, and gave me a number that didnt exist. apparently there were three more sons in holland, and i left a message on an answering machine after a (what i presumed to be) dutch "please leave your name and number..." routine.
later, the son from wa rang me. i guess the nephew had better luck getting on to him. he was angry that switchboard had made him wait (on long-distance) while i was in a family meeting (rapid deterioration in a woman with extensive stage small cell lung cancer). but he quickly got the picture. no he couldn't come, he said, because he didn't have the money. and he didn't want to be stuck here if she died. did he wanted mum to go down to adelaide or melbourne for further investigations? no doc what's the point? shes in her eighties and shes had a good life. i promised him id let him know how things went. later on i overheard some nurses talking: apparently my patient is loaded. ahh...
i shut my ears and quickly moved on to the next patient.
her closest family was her dead husbands nephew 110kms away. he was the only one that seemed to care (i will try to come up doc but it wont be until the weekend cause im working) but didnt feel comfortable making medical decisions for her. there was a son in wa, he said, and gave me a number that didnt exist. apparently there were three more sons in holland, and i left a message on an answering machine after a (what i presumed to be) dutch "please leave your name and number..." routine.
later, the son from wa rang me. i guess the nephew had better luck getting on to him. he was angry that switchboard had made him wait (on long-distance) while i was in a family meeting (rapid deterioration in a woman with extensive stage small cell lung cancer). but he quickly got the picture. no he couldn't come, he said, because he didn't have the money. and he didn't want to be stuck here if she died. did he wanted mum to go down to adelaide or melbourne for further investigations? no doc what's the point? shes in her eighties and shes had a good life. i promised him id let him know how things went. later on i overheard some nurses talking: apparently my patient is loaded. ahh...
i shut my ears and quickly moved on to the next patient.
11.6.10
tyranny of distance
the man looked pretty good for someone who had just had fifteen minutes of cpr.
out of hospital vf arrest. bystander cpr until the ambos arrived. four shocks to get back into sinus rhythm. there were massive tombstones on the ecg. we thrombolysed him but his chest discomfort and ecg changes persisted. time to get him out of here. fast.
if you live in mildura and have a cardiac arrest, on average your outcome will be worse than if you lived in melbourne. it's closer to adelaide but they'd rather you sent your patient to melbourne, even if its almost twice the distance, because after all mildura is in victoria. even if you always send your cardiac patients to adelaide because there is a more integrated, easier to navigate cardiology service there and your boss has mates there. even if the patient has already been accepted and has a bed waiting for them in adelaide. even if your patient has failed thrombolysis and is rapidly developing q waves.
sorry fellas, but i don't give a shit whether mildura is in victoria or south australia. it might as well be in afghanistan or on the moon if you are going to keep acting like dickheads. this man needs a hot plasty and he needs to be retrieved. end of story as far as im concerned. but in the end, it took as long to resuscitate and stabilise my patient, talk to the family and admit another two patients, as it took the retrieval guys to dick around and try and handball responsibility to each other, until finally they dumped it on the rfds.
it's just not good enough.
out of hospital vf arrest. bystander cpr until the ambos arrived. four shocks to get back into sinus rhythm. there were massive tombstones on the ecg. we thrombolysed him but his chest discomfort and ecg changes persisted. time to get him out of here. fast.
if you live in mildura and have a cardiac arrest, on average your outcome will be worse than if you lived in melbourne. it's closer to adelaide but they'd rather you sent your patient to melbourne, even if its almost twice the distance, because after all mildura is in victoria. even if you always send your cardiac patients to adelaide because there is a more integrated, easier to navigate cardiology service there and your boss has mates there. even if the patient has already been accepted and has a bed waiting for them in adelaide. even if your patient has failed thrombolysis and is rapidly developing q waves.
sorry fellas, but i don't give a shit whether mildura is in victoria or south australia. it might as well be in afghanistan or on the moon if you are going to keep acting like dickheads. this man needs a hot plasty and he needs to be retrieved. end of story as far as im concerned. but in the end, it took as long to resuscitate and stabilise my patient, talk to the family and admit another two patients, as it took the retrieval guys to dick around and try and handball responsibility to each other, until finally they dumped it on the rfds.
it's just not good enough.
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