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.
30.5.10
just another afternoon in ed
massive eyebrows lady had a great murmur that you could almost hear without your stethoscope. her lungs were filled with crackles and her troponin was 15. but she also had a low ph, a bsl of 24 and a tongue as dry as the sahara. i gave her some fluids and she got better than she got worse. her family gathered around with frowns and said they wanted full resuscitation. palliative care fail.
gcs 4 man came in with a fever and a raised troponin. he had a shearer blue singlet on and a permanent trache thanks to a floor of mouth scc. he had no neck (dissected away long ago) and no blood pressure. he also had no massive intracranial haemorrhage or cerebral mets on ct, which we were rather hoping to find. so we had to take him to icu because the ward couldnt manage his sats of 78%. yet another palliative care fail.
bmi 40+ man had no neck either. but he did have a pco2 of 113. his family attempted to keep him awake while we put him on bipap and tried to reverse his warfarin so we could tap his pleural effusion. finally at 11pm we decided to bite the bullet and tube him. the anaesthetist didnt want to come in but in the end she relented. perhaps it was the confidence (or was it panic) in my voice. thankfully it only took her three goes to tube him with the bougie. she also left me to check the tube position, put in a ngt to decompress his stomach, make up the ventilator settings, write up sedation, work out which inotrope to use (i wasn't too thrilled with a sbp of 65) and talk to the family. fortunately, it seemed that i had learnt something from my icu rotation after all (entirely through osmosis of course). and the icu nurses were very patient. another life saved.
but now i have a cold. hooray!
gcs 4 man came in with a fever and a raised troponin. he had a shearer blue singlet on and a permanent trache thanks to a floor of mouth scc. he had no neck (dissected away long ago) and no blood pressure. he also had no massive intracranial haemorrhage or cerebral mets on ct, which we were rather hoping to find. so we had to take him to icu because the ward couldnt manage his sats of 78%. yet another palliative care fail.
bmi 40+ man had no neck either. but he did have a pco2 of 113. his family attempted to keep him awake while we put him on bipap and tried to reverse his warfarin so we could tap his pleural effusion. finally at 11pm we decided to bite the bullet and tube him. the anaesthetist didnt want to come in but in the end she relented. perhaps it was the confidence (or was it panic) in my voice. thankfully it only took her three goes to tube him with the bougie. she also left me to check the tube position, put in a ngt to decompress his stomach, make up the ventilator settings, write up sedation, work out which inotrope to use (i wasn't too thrilled with a sbp of 65) and talk to the family. fortunately, it seemed that i had learnt something from my icu rotation after all (entirely through osmosis of course). and the icu nurses were very patient. another life saved.
but now i have a cold. hooray!
15.5.10
just wing it
i can't believe it's only been five days since i started up here in mildura. those days have been filled with so many... decisions. big important urgent decisions that i feel unprepared for, but nevertheless have to be made and there is no one else to make them.
so i just wing it.
do i resuscitate this 85 year old man who's just dropped his gcs and blood pressure in the rehab ward? do i take him to icu and scan him head to toe? just wing it.
do i admit this apparently well (albeit slightly smelly) guy who collapsed between placing his bets at the local tab and drinking at the bar, but with no risk factors on history and no abnormal findings on physical examination? and after i send him home, what do i do when the lab rings me with a positive blood culture for staph aureus in 2/2 bottles? just wing it.
do i advise the gp that it's okay for his patient to stop taking his beta-blocker, even though he came in with ischaemic sounding chest pain, dynamic ecg changes and moderate cardiovascular risk factors, because his enzymes and stress test were negative? just wing it.
and to top it all off: i have a scary intern.
so i just wing it.
do i resuscitate this 85 year old man who's just dropped his gcs and blood pressure in the rehab ward? do i take him to icu and scan him head to toe? just wing it.
do i admit this apparently well (albeit slightly smelly) guy who collapsed between placing his bets at the local tab and drinking at the bar, but with no risk factors on history and no abnormal findings on physical examination? and after i send him home, what do i do when the lab rings me with a positive blood culture for staph aureus in 2/2 bottles? just wing it.
do i advise the gp that it's okay for his patient to stop taking his beta-blocker, even though he came in with ischaemic sounding chest pain, dynamic ecg changes and moderate cardiovascular risk factors, because his enzymes and stress test were negative? just wing it.
and to top it all off: i have a scary intern.
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