small medic mini-blog

You can usually tell the mood in the department early on, right from the peripheries. When it's busy, patients sit in beds out in the corridor; specialty staff are stuck down in the department; the waiting room heaves and it is standing room only. Tempers flare. And, factually, it is worse for patients.

Sometimes, in this mess, the word “difficult” (or challenging or rude or...) gets brought out. Because some people end up expressing themselves loudly, and that is intimidating. Lots of them express a fear of getting lost in the system. When it is crowded, and it's taken longer than they expect to be seen, a few people have come up to staff to make sure they haven't been forgotten. (They haven't, 99% of the time. It genuinely is a stark matter of supply and demand.)

I think it's the same with children who come in with “behaviour escalation”. They fall between CAMHS and medical services, but neither thinks it's their problem to solve. I suspect this is because neither has particularly good solutions for it. Yet they undeniably are “difficult to manage”, hard to put in a box, sometimes end up hurting themselves.

I think all of them just want to be heard.

Even in a district general hospital, each patient makes up one of 60-120 patients in the department at any time. By my estimate, I spend maybe 20-25 minutes actually seeing and examining patients; the rest of the time is spent in front of a computer, so away from patients, documenting, referring, requesting scans, chasing bloods... All “behind the scenes” work, and from the outside, looks like inaction.

How do we fix this? Can it be fixed? What happened if patients were given a more granular breakdown of progress? How do we even communicate the hundreds of tiny steps needed to decide on disposition? How do we make people feel heard?

#reflections #clinical-communication

done!!!

I'm not done with medical nights just yet, but I rather enjoyed this set of nights – good team, good reg, and while staffing was lighter than usual, our ward cover overnight is ridiculously good for similar hospitals.

there were some very unwell patients, with a variety of pathologies, and we as a team did deliver some genuinely lifesaving care (this can be rare!)

there was also the usual frustrations: unprofessional behaviour, people trying to shift risk and blame to doctors for no discernible reason, not getting any rest with back to back emergencies. The latter, of course, being unavoidable sometimes; the former, systemic problems with no single solution.

sometimes it's about winning colleagues over to the side of the evidence. The temptation to just do something about asymptomatic hypertension is great. I have been guilty of succumbing to the “5mg amlodipine in the middle of the night”, a medication that will certainly not take effect by the time the nursing staff next take the poor patient's blood pressure. And yet, it's a strategy that just makes the healthcare professional feel better for having done something.

Sometimes, though, there's a glimpse of the type of medicine that compelled me to go for emergency medicine training.

Joining a colleague at the bedside of an unwell patient, and just getting stuff done. Putting the evidence together to try and figure out what was going on and how to improve their physiology.

And sometimes we (the medical team) actually arrive to a patient in the middle of a life-threatening pathology, have the means to correct it and can immediately see the result.

What a privilege it is! this is the meat and bones of acute medicine and it is brilliant when it works.

(the heart and soul, of course, being rather different. I'm sure I'll talk about it one day, it's very Pratchett)

First concert event of the year the week before last.

Unusually, we had training earlier in the day before the concert in the evening – a nice touch, I thought – meant that we could practice on site. also, because it's hard to get mojo barriers (the crowd barriers that you find at concerts), and our mockup has been broken multiple times by larger members of the team. As I've found, I've found it hard to mock-up, or break down, the physical skills and movements for the thing that worried me most – crossing crowd barriers. so I've been winging it, basically.

As luck would have it, I was placed in a team with the tallest people around, both during the training and the actual event…

The height difference is usually nothing more than a funny quirk, a visual joke. Sometimes even a benefit. Tall members mean they can reach and see things I can't, or catch me where I'm weak. And it was good for those pesky barrier crossings because they could spot me.

Halfway through the main act though, I realised the two tall lads were talking to each other, then to me as an afterthought. It's easier for these tall guys to take up space, to be noticed, to be recognised as The Medic. More of an art to deflect attention.

MRT days make me mindful to be assertive. I am naturally quite soft-spoken and averse to conflict. But the more “go with the flow” I am in MRT, the easier it is to ignore me. Not that I must be heard at all costs. But this extends to being kept in the loop. As much as I can interpret my team's actions because we have a shared mental model, I appreciate sharing that communication…

*He's a student HCPs, and I find they fall easily into a clinical lead role. Those who started volunteering as first aider without necessarily a clinical background tend more to find the operator role more natural, I think.

When you're physically small, it takes effort to occupy space and be heard and lead. Especially when it goes against your own nature. It's not just an amusing look…

#crowdmedicine #MRT #volunteering #personal #reflections

“had a group task with someone [...] and halfway through I literally told him, “please can you stop talking for a sec and let [another group member] speak””

still can't believe I did that. my sharp comment was probably the sharpest thing I'd said all day because I was much nicer back then...

this was selection for a certain team in early 2020, scant months before first lockdown in the UK, and this remark was towards a good acquaintance – who, as much as we get along, has an unfortunate tendency to talk absolute rubbish

(he did not make the team)

#MemoriesUnbidden

searching for guidelines for an audit for children with learning disabilities and it's low key depressing how many of those guidelines are focused on * behaviour that challenges *

many times I feel like a lot of health and school measures are for the convenience of the adults, but this is saying it as someone who doesn't need to stop these children from throwing things or hitting/biting/kicking other children.

there are also precious few guidelines on chronic pain in children that aren't condition-specific, which is vaguely interesting.

#pain #paeds #reflections

was with the same reg on my last set of on calls! lucky me.

unfortunately one of us is turning out to be a magnet; had plenty of unwell patients. was this the on calls where he decided a very frail patient needed a relook laparotomy? maybe. he seems to have at least one going to emergency surgery every time I'm on call with him.

if you wonder why healthcare staff have such superstition: we have so little locus of control it feels better to blame it on someone saying the Q word or someone being a magnet rather than a strained system.

nonetheless.

have seen many people's bums and carefully squished many people's abdomens. learned a lot. got some pointed but well meaning feedback from said reg.

the ol' career instnct is pointing towards ICU as a way to: * maintain medic diagnostic skills * airway skills * much physiology * learn some surgery-adjacent skills

#surgery #career

UK medics will appreciate: ARCP season is upon us. My ES does not know how to fill the forms in properly. Which begs the question, if there are so many hidden tickboxes, what measure of clinical competence is that?

#career #fy1

my registrar and I sat in ED at 3am and he just went “I want to cry” I made an unintelligible sound and we moved on

heck of a night to finish on, first he went to theatre and left his bleep

cue loads of angry referrers leaving passive aggressive mesages in the notes

then the urine analyser stopped working, then the BLOOD analyser stopped working????

then a crash bleep for “cardiac arrest in CT” and the reg thought it was one of our patients

it sure beats the night where three people got unwell the hour before handover tho

or when I went to assess a patient, left the ward, and was bleeped 5 mins later with a much more worrying update

overall still enjoyed it though, much better vibes than medical nights – I guess partly because we know what's going on with each person on the list, the chance to go between the wards and ED, and seeing patients get better...

#surgery

as a junior

Out of hours, you're most likely to be called for hyperactive delirium, but your workup remains the same.

My finals notes: https://smolmedic.github.io/#Delirium

establish the baseline

• How do you know they're confused? Has anyone taken a collateral?
• “patient is a poor historian” just means you don't have enough sources of information
• Sources of information: NOK, carers (care agencies, sheltered accommodation managers), care home staff, previous therapists docs
• document who gave you the collateral

approaching the patient

• usual physical examination and secondary survey – looking for any source of infection, signs that they injured themselves as a result
• mental state examination (https://smolmedic.github.io/#Mental%20state)
• can they tell you about any delusions or hallucinations? voices/noises/telling them to do things? seeing people/things/animals? are these frightening? these can contextualise behaviour, help you reassure the patient and risk assessment
• the last one can help you step into their world for a bit

bedside investigations: aim to rule out reversible causes

• think U PINCH ME
• retention – bladder scan
• hydration/nutrition – fluid status, bloods
• metabolic – bloods, blood sugars
• environment – environmental stimuli can sometimes be a focus for a delusion/hallucination (i.e. misinterpreting stimuli) – hearing aids in, glasses on!

bedside paperwork: working with nursing staff

• bowel chart – they must poo. nuff said. “type 7”/watery stool may be overflow
• food chart – if not eating, look in mouth (easily missed) – mouth care? thrush? cognition = needs prompting to finish food?
• behaviour chart – full of incredibly useful information. are they sleeping at night? consultants might like sedatives, but as a junior, making sure they have adequate pain relief can be an easy win

suggestions for management

• family visits can help re-orient/reassure esp with paranoid ideation
• 1:1 may be needed if very very hyperactive
• MHLT can help +/– old age psychiatrists to help with antipsychotic dosing, weaning of psychotropics, follow up/discharge planning e.g. for dementia unit
• Meds a geriatrician might use (from local experience): risperidone/olanzapine esp with violent behaviour, quetiapine with PD patients (less anti dopaminergic effect I believe), sedatives to even out sleep pattern

Successfully diagnosed viral labyrinthitis in someone who had “failed PT/OT” (therapists declined referral due to no clear indication).

Very interesting conversations about AKI and delirium, as always

Got in touch with [external hospital] and discussed TWO patients in 20 minutes?! (I was once on hold to them for just under an hour)