religion, ritual, and surgery

Medicine is strange. And surgery is so weird in so many ways. Medics don’t often talk about death- I mean not really. We talk in a matter of fact way about patients dying but we don’t talk about the meaning of death or what we each believe about the afterlife or whether there is such a thing as the spirit etc.

I suppose you would assume that medicine is a materialist trade, however there seems to be no concept of the body and ‘soul’ as one unified thing. To think this way would require some trepidation when approaching surgery, a holistic approach to patient care (and everything, really), and some sort of sense of connection and communication that just isn’t there. The reality is we seem to have a very dualist view, where the body is nothing more than the vessel for the mind/soul, and a very reductionist, matter-of-fact view of the living human body in disease states.

The there are these odd moments that just introduce new behavioural elements that are just at odds with this cut-and-dried attitude. Take surgery. Surgery is really the closest you can get to another living human being. It’s a really weird process, it almost strips the body of any mystery at all, but at the same time exposes so many intricacies and answers absolutely no questions about who we are.

I started to find it really funny, the way we behave around surgery. The operating theatre is a very holy site. You have to change into clean, loose fitting, uniform clothes to enter. You must cover your head. It’s brightly illuminated with special lights. Those closest to the procedure have to ‘gown up’ covering their arms and often parts of their faces. The surgeons wash their hands before they enter, in a specially designated sink, a ritualised washing routine, often recommended that you repeat it three times. No one can touch the outside of their gowns, including them, or they are unclean again and cannot continue with the procedure until they have re-purified themselves.

All of this is done while having matter-of-fact conversations about departmental rotas or what’s for lunch. But the behaviour itself is pure pseudo-religious ritual.

(Yes, the rules are developed for the sake of infection control, but people didn’t just make them up from nowhere. Our culture, our internalised unvoiced spiritual ideas, our religions, all inform the ways in which we take data about prevention of infections and develop systems to apply that in the workplace.)

 

It’s funny to me. I start to notice the religious rituals all around in every day life- making a cup of tea for example, earth water fire and air (tea, water, heat, steam), like an old cauldron. Lighting a cigarette. Clubs and bars- with the optics and coloured lights like a focal altar, alcohol being served, music playing, dancing, stained glass.

 

I love seeing it in medicine though especially in surgery, when people are dealing with the raw material of human life and talking so nonchalant but performing these rituals. I think it’s nice, it’s reassuring. There needs to be a sombreness there.

 

 

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surviving night shifts

Another advice post, as I’m aware people are due to start in August. This is what works for me and may not work for everyone… here you go.

Also, this applies to runs of nights. The new contract which could see people doing a day then a night then a day etc, would render this advice pretty useless.

  1. DARK. The absolute key. before your first night shift, get some binliners or similar, and tape them up over your window. All over, so you do not have a crack of light coming through. Couple this with some thick curtains. The room needs to feel dar enough that you could believe it’s the middle of the night.

2. FOOD. Your GI system suffers in nights. You’re getting that sudden hunger that comes from being awake past 1am, but you also still get hungry in the day. Your body doesn’t know where it’s at. What I found works, is, eat an evening meal before work, then have a pre prepared healthy meal to eat during the shift, then when you get home, have porridge before you go to bed. Or some other low GI food. Otherwise you wake up about 3pm starving hungry. Tempting as it may be, don’t live off takeaway.

3. HYGIENE. Brush your teeth before each shift. Pretend it’s the morning, even if you’ve been awake all day. Otherwise they get fuzzy.

4. TIMING. For an 8-8 shift, aim to stay up until about 11am when you get in. Do some simple tasks like prep food for the next shift or laundry. Stay out of your bedroom. Don’t have any caffeine. Then when it’s time to sleep, go into your dark dark room. Set an alarm for 6pm. With any luck you’ll sleep right through.

 

 

saving which lives? why?

imagine you are 79. You have a heart attack and come into hospital. I treat you, and you get better. It’s difficult to know for certain, but let’s assume I saved your life. Let’s assume you would have died without medical intervention. The doctors start you on medicine to prevent you having another heart attack and you go home.

Six months later, you start to develop dementia. You become more confused and frail. In another year or so you end up having to leave your home and live in a care home. Most of the time you are not sure where you are or who the people around you are. You develop an infection and come back into hospital. We treat the infection with IV antibiotics which means we put needles into your veins to take blood and give medicine. Because of the dementia, you stop eating and drinking. This is usually how people with dementia die. Maybe your mind has already checked out, maybe your body always intended to go age 79 from a heart attack, maybe on some level you have just had enough. You don’t eat and you don’t drink. We keep on putting needles in your arm to give you more fluids. You are distressed by this. You keep pulling the needles out. We keep putting more in. It is becoming harder and harder to find a vein. Your grown-up children insist they want everything done for you.

Eventually you die, in hospital, confused and unhappy.

Meanwhile there are children all across the world dying from lack of clean water and easily treatable dehydration due to diarrhoea. There are women dying from complications of childbirth that could be easily managed. There are also people dying  in their 70s from treatable conditions such as heart attacks and strokes, having lived long and full lives.

Your children do a sponsored walk to raise money for a medical research charity, in your memory.

 

dystopia/ where we’re headed

as doctors we aren’t often involved in the direction of medicine. We are technicians, trained to administer and perform. We are not usually the people directing research or policy. As such how often do we assess the bigger picture? New advances are introduced and we dole them out.

Sometimes I like to let my mind wander. Although malaria, diarrhoea, and childbirth are probably the biggest killers worldwide, and although we currently have the expertise and tools to tackle these, medical research is focussed on conditions that affect rich people the worst. We are reaching a point where people in certain countries can expect to live longer and longer (though not necessarily with quality of life), and where researchers are looking at causes of and antidotes to aging.

(big topic… lots more to say, but not right now.)

What’s the point of this. Where’s it going? Are we really moving towards a technology that will allow deathlessness? Medicine that will allow people to live forever? And if so, how would that be accessed? It surely wouldn’t be available to all, on the NHS or standard insurance policy, free at the point of demand.

No. Just imagine we discovered a way to stop aging, to stop mortality.

That would only be available to a select few. The extremely wealthy and powerful, the rulers, the people who hold all the cards, the dictators of this world.

A lot of the time it’s not revolution that topples tyrants. It’s simply age and/or mortality. Like Charlie Chaplin says, ‘so long as men die, liberty will never perish’. SO what happens when those men no longer die? The dictators and the tyrants, the super-rich.

 

 

Sometimes I think about this when I’m at work…

 

 

sick days

Lately I have been really bothered  by doctors’ attitudes towards taking sick leave. It’s obvious that we’re all overstretched, and taking sick leave can mean collleagues are stretched further. It should also be obvious that human beings get sick from time to time and that when they do, they can’t perform a strenuous and difficult job.

I think most of us feel guilty when weare off sick. We encourage each other to feel bad about it. How many times do you hear people say of a colleague ‘they’ve called in sick’? But never ‘they are off sick’. Even if you’re at home with d&v barely able to crawl off the toilet, it’s still framed as ‘you decided to call in sick’ rather than ‘you’re too ill to come to work’.

Also, how often do you hear colleagues telling others ‘i’ve never had a sick day, i can’t understand why people call in sick’? As though good health is a measure of good moral fibre. What does it say about us as doctors, people charged with caring for the sick, if we view sickness as a sign of weakness, a moral failing? How can we as doctors, faced with the evidence of our day to day working lives, not realise that sickness is something that can affect anyone and everyone? How can we reassure patients that there’s no proven reason ‘why me’ while all the time believing its our own work ethic and sense of responsibility keeping us well?

The more I think about this the more I see this insistence that illness is the choice of the weak, rather than an inevitable consequence of being a mortal organism, as a crude psychological defence mechanism against accepting the possibility that you too may get cancer or a stroke or pneumonia, and you’re not immune. That you’re no different and no less vulnerable than your patients.

 

 

 

 

Lost in it all

i really feel that I don’t know who I am any more. I’m not the same person I was when I started fy1 but I haven’t developed or matured- I’ve just gotten numb, task oriented, focussed on simple rewards.

I feel like as doctors we see a lot of life but we stay one step removed from it, like we think we’re just observers, in a boat floating on an ocean and not just flailing around in the sea like everyone else. We see people getting sick and dying, we see reminders of our own fragility and mortality every day and we break it down into liver function tests and inspiratory crackles. People tell us about the terrible things their parents did to them and we type up referrals for cbt.

We keep ourselves very busy, and we maintain this professional structure that gives our lives narrative, a clear progression from point a to point b, registrar to consultant, and always exams and hurdles and things that take all our time and concentration and make sense, if you work really hard you will pass eventually and you’ll move on to the next stage; as facile as school. We keep this focal narrative of our lives linear, we give ourselves this path and we don’t look left or right, we just keep walking.

A lot of the time i feel like we’re just trying to keep ourselves from thinking too much.

Lose yourself

over the time I’ve been working as a doctor I really feel like I’ve lost my sense of who I am. I don’t know if this is all due to the job, it’s partly age and partly circumstance too. But being a full time junior doctor has certainly allowed me to lose sight of myself and what’s important to me in a way I didnt think was possible.

i think a large part of this is the nature of the job and the way we work. I often spend more than twelve hours a day at work, I am living away from friends and family. This means any free time I have in the evenings is gone on eating, doing laundry, and staying in touch. Free weekends or annual leave are spent travelling home and catching up with people. I literally have no blank time. Those hours I might normally have spent reflecting, contemplating life, listening to music, have disappeared. I have barely paused for thought this past year. That time seems like nothing time, blank space, until you lose it and realise how important it was.

The rota, switching from days to nights, doing 12 day stretches, leaves you exhausted often. The work day leaves you hungry with no time to eat or drink, and often no time to pee. Your mind is occupied with jobs, clinical problems, patients concerns and demands of other staff members. You have no space to really step back and think about what is happening, what you are doing and how you feel about it.

The desires you experience are intense and they are to eat, to sleep, and to use the toilet. So often that’s all you know you want. You can’t think any broader than that about what you want from life, from your job or from the next few hours. The higher functioning part of your brain is focused on getting your jobs done. Basically the only bit of your mind that’s really feeling anything beyond work is the reptilian brain.

I know I spent most of the last year very certain I wanted a good nights sleep, and without any real ideas beyond that. How easy would it be to convince myself that I should really apply for training and just keep down this path because it’s the obvious next step? Keep working, keep busy, keep the money coming in. I know, because I remember from before, that that’s not what I want. But after a year in the job its easy to forget who I am and whatever the hell it was that mattered to me in the first place.

leaving medicine

as someone who has been googling ‘quitting medicine’ since first year of medical school, I often come across blogs by doctors who want to leave, or say they want to leave. I always recognise a lot of what they are saying. I’m sure I am not alone in that reading those blogs gives me a lot of comfort; I’m sure writing them gives some comfort too.

I am also somebody who wants to leave medicine, however to a certain extent I have made my peace with where I’m at right now (FY2). I have my own strategy going and recognise that having been fool enough to do a medical degree there’s really no easy way out.

Two blogs I’m enjoying currently are the disillusioned medic and the disenchanted medic.

There’s a couple of recurring themes I can’t help but notice about these ‘I hate medicine and I want to leave’ blogs. They are pretty much universal to every blog I’ve read and they jar for me. This is not directed at the two blogs just mentioned, I find them both refreshing and enjoyable. This is a general comment on ALL the ‘I want to quite medicine’ blogs and posts I’ve seen.

One is that despite the authors saying how they don’t like medicine and feeling that it doesn’t ‘fit’ them as a person, and is not who they really are, the word ‘medic’ is invariably in the blog title, usually with some kind of negative precursor. It’s interesting to me that despite feeling totally done with medicine, when it comes to naming the blog and thinking ‘what am I about, what will make me interesting to people’ the first identity label that we have for ourselves is still ‘doctor’. It’s what makes us important, interesting, and worth reading. This whole concept of doctor as something you ARE rather than something you do, a source of personal identity and worth rather than a job, I think is a big and crippling deal for a lot of people.

The second thing is there seems to be an inherent view that work SHOULD be fulfilling, that you should be able to find a job which stretches you to your full potential without exhausting or terrifying you, and that you should be able to find paid work which utilises your talents. I’m not sure why this is, I can only guess it’s because most of us went straight into medical school and all the way through medical school aren’t we promised a rewarding career, a fulfilling job which pushes us to deliver the very best we can achieve in a safe and supportive environment, aren’t we always told it’s the best job in the world and how lucky we are and we’re gonna love it? So don’t we just believe it, and come out into the NHS fully expecting that such a job exists and is within our reach? And aren’t we so fucking disappointed when it’s just getting shat on, and worked to exhaustion, and paying the bills?

I know I genuinely though for a long time that there was a job I could find which would use all the best parts of me and allow them to grow and would also allow me to have a social life.

My views have changed. I know that clinical medicine is not for me and I know all the reasons why. I also know that leaving does not mean walking into some other full time job that will fulfill me so much more. I know that thanks to my own idealistic desires in life, my good faith, and the way capitalism and society works, working a paid job will always come with its frustrations, miseries and necessities. I’ve realised it’s important to work out what you want from life, and what you can and can’t have, and where your priorities lie.

For example, if you want to truly help others in a manner free of red tape, or you want to pursue your artistic talent, then you most likely can’t have a mortgage.

 

 

Practical FY1 tips- how to run your day

This is the very basics and what I think will be useful to know when starting out. This is how I organise my day as a typical (surgical) FY1 ward day. (Still applicable to medicine tho). This may also help dispel the mystique for those who think being a junior doctor is exciting 😛

Disclaimer: This works for me and allows me to manage big workloads and get everything wrapped up on time. It may not be the most efficient way for YOU. Find what works. Plus, different hospitals organise differently and this may not be applicable everywhere.

7:45 am- come in 15 minutes early to prepare the list. You should have updated as much as possible the day before and usually just need to open it up on the desktop along with the hospital patient tracker system and check who has moved and read any outstanding scan reports. Print out enough copies for everyone who will be on the ward round. Master printing double-sided- this will mark you out as a good FY1 (I’m not kidding).

On the ward round, as well as writing in the notes and checking the jobs, you need to make sure you keep a jobs list. It’s best if EVERYONE aims to keep a jobs list- that way nothing gets missed. Write the jobs next to the patient’s name on your list. Don’t assume your registrar will have time to sit down and clarify jobs after the ward round- they often don’t. If you have queries about management plans (ie whether the patient will need follow up if you’re doing a TTO) ask then and there. It may be hard to get hold of your reg again once the ward round is over.

After the ward round, it’s tempting to immediately start doing jobs- especially when you’re new on the job the list just looks overwhelming and you want to get it done. Stop. Take a breath. Maybe get a coffee if there’s time. You need to organise the jobs. What I like to do is sit down with a piece of paper and write out the jobs I need to do by category. Ie I will put the heading ‘TTO’ and then write down all the TTOs I need to do, with a check box next to each one. I will star the more urgent ones- the people going home immediately or that day.

Once you have all your jobs listed it’s time to get cracking. First, get all the imaging, scans and procedure requests handed in. That way your patients will get their investigations done as soon as they can. Tick all the requests and jobs off as you hand them in.

Next you need to get the urgent TTOs done. I didn’t get this at all at first- I completely failed to realise that TTOs are a big priority. After all these are well people, ready to go home. Surely there’s more urgent things to do. But the hospital is an organic thing, and there are people coming in the doors of A+E all the time which means getting the well out is a major priority. Plus, if you get the TTOs done first the nurses will stop bleeping you about them and you can actually get on with things rather than having to answer your bleep every 2 minutes.

After that get any other outstanding stuff done. Bloods, cannulas, discussions with microbiology, referrals etc. You should now have most of the jobs done that need to be done that day.

At this point it’s probably a good time to get lunch. You can expect all the bloods to be coming back early afternoon so this is a sort of natural lull in proceedings. It’s a rude awakening when you realise there is no protected rest time for junior doctors and you will get bleeped throughout lunch to ask if scan results are back, double check management plans, ask for cannulas etc. (a common reason to be bleeped at this time is to find out if patients are allowed to eat lunch or need to be kept nil by mouth). If a request is non urgent it’s perfectly okay to ask them to wait half an hour before you come. You really do need to eat and drink and no one else will make sure it happens. Take twenty minutes and then get on with it again.

After lunch it’s a good time to sit down with the list and update the management plans and chase the bloods. Chasing blood results means looking at the results, acting on anything unusual (high inflammatory markers, drop in Hb, deranged electroloytes etc), it also means simultaneously writing these results into the list. It’s a real drag sitting down for what can easily take an hour and typing numbers into small charts, and it initially feels like you’re wasting your time, but your seniors will expect to see it there and it does need doing.

While you are doing this think about who will need blood taking the next morning to check on trends. If you think someone needs bloods the next day, print out the form then. Make a note on the list that you have put bloods out for them. Now is a good time to start looking out for scan results too. Speak to a senior if anything gives you cause for concern. While you are chasing, make a list of the jobs being generated (ie does someone need potassium prescribing, can someone else go home now the blood results are ok?) If some bloods aren’t back call the lab to check they have them. If not you will need to check with the patient if the blood got taken- if not you will need to bleed them. Add this on to your list of jobs.

Check the theatre list for the next day and add the inpatient stays onto your list. Print blood forms out for them too if necessary.

Go round the wards again, putting out the blood forms and doing the new jobs. Continue with the rest of the jobs on your jobs list- eg TTOs that need to be prepared for the following day. At this point everything is now sorted for tomorrow, and you can just keep dealing with problems as they occur.

It’s a good idea to try and get hold of your registrar either just after chasing or now (try to reach them by 3). See if they are able to go through the patient list with you and review results. Complete any further jobs.

Go over the list once more, checking you have seen all the blood results. Take off the people who have gone home.

Go home yourself.

  • I hope that helps. Don’t feel bad if you can’t be on top of things from day 1. My first weeks were a struggle, I rarely managed to eat or drink during the day and usually finished at least an hour and a half late. It will come. It’s a tough learning curve, and sometimes even if you are very competent there is just too much to do. You will find your level.

Good tips for cannulas: http://theemtspot.com/2009/08/04/six-techniques-to-nail-the-iv-every-time/ – I found this advice extremely helpful during a rough ward cover shift especially number 5.