Beyond fucked 

Beyond fucked 

Everyone has their own ideas about what constitutes being totally fucked, by which I mean that level of gubbedness that is unsalvageable and not worth even trying. There are various ways of thinking about it,  you can do a P-possum, check their base excess and pH, look at them from the end of the bed, but one thing is sure. There is rarely a return to health from being totally fucked. It can be depressing.

Bighospital is totally fucked just now….

We have 8 nurses off sick on my ward alone; 5 with either flu or vomiting and 3 with stress and this situation is repeated everywhere.

We have no beds for elective operating as we are full of unwell medical patients. We do physically have beds, but we have no staff to open them.

We have an A&E that is full and overflowing with staff at the ends of their tethers. Patients are being told they have inappropriately attended and should have waited 2 hours to speak to NHS 24 and then 6 hours for a GP to come.

We have trainees (entitled and snowflakey in a way I never was) being taken off on call and moved to elective operating lists in case they complain in their GMC survey and we lose them entirely. Newsflash to anyone who thinks like this: this isn’t school, you get a salary, start delivering some value for money.

We have some consultants who won’t do anything that isn’t in their job plan and obstruct and hinder attempts to improve service. “I’m a consultant surgeon, nobody can tell me what to do”…you’re a salaried employee, not a deity.

We have managers who can’t manage. Leaders who can’t lead.

Bullying, misogyny and bitching are endemic.

Patients on the ward are sometimes not washed or fed because nurses are filling in endless paperwork and “magic stickers”* for every problem that must be completed or some nurse manager will explode.

I can’t get the elderly and dependent patients out of Bighospital because there are no carers to look after them in the community. They remain there, pathetic and heartbreakingly vulnerable, not having been home for weeks. These people haven’t seen the sunshine or felt the wind on their face, and they bear it politely and impassively in a way I could not.

We are beyond fucked. It is the same everywhere, I’m not sure it can be fixed and I suspect that our conservative government doesn’t care if it dies.

*magic stickers are Bighospital’s response to all problems. For any target or goal or other utterly unnecessary nonsense that trained nurses and doctors do anyway there is a sticker. For example; a doctor is asked to review a patient with a low blood pressure. The patient is 17 and weighs 50kg and is asleep, her BP is 80/50mmHg. It was similar to this when she was awake. This is normal, but the nurse has to mention it to the doctor. A year ago we could say “that’s fine. Thanks, I’m ok with that” now the junior must complete a fucking sticker and a complete assessment and stick it in the notes.



What do I hope the outgoing FY doctors have learned after their time in surgery? For the surgical futured ones there are practicalities like tying a knot properly and closing the skin and inserting ports, as well as hopefully communicating with them the “hidden curriculum” of hard work, professionalism, kindness and care. The ones destined for general practice or other specialties. Someone much smarter than me wishes that they leave with foresight, insight and hindsight, which I love. 

One of the things I want them to leave with is how to recognise dying and manage it well. There are many phrases about knowing when not to operate being more important than when not to; same with ITU admissions and critical care beds. It is really hard to tell someone that they are dying, you can’t deliver it in the same way you tell them that their CRP is going up or down. It takes time and compassion and usually briefly takes a piece out of you emotionally. 

Do not avoid theses conversations, don’t prolong death with TPN and blood transfusions and pointless antibiotics. Do not shrink from your responsibilities and hide behind interventions and futile treatments. Recognise dying and help your patient and their family face it. It’s important. 

Men: desist from this thing immediately please

Men: desist from this thing immediately please

Imagine the scene, you’re sitting listening to a speaker opine on a topic and when they reach their concluding slide instead of a great slide summing up their message they have a picture of their children. Pause for us all to admire Thomas and Em’s extreme cuteness. Then they make some annoying reference to their progeny being way smarter than they are or some other shitey humble brag. 

A certain subset of men then make reference to their amazing wife (a stay at home mum) who keeps them in clean shirts and feeds everyone. I don’t know how she does it! 

I feel the more kids they have the more likely they are to mention it. 

Why do they do this? Women don’t. Is it to brag about their overall successfulness? “not only have I conducted a randomised controlled trial but I have fathered three children”? It’s vile. If I ever get to the point where I am important enough to be chairing meetings I’ll start telling the offenders that it is pathetic. 

Take the slide of your kids out. Don’t ever make reference to them again in a talk. Nobody cares about your children. 

Ward Round Bingo 

Ward Round Bingo 

We have all been there, stuck on a tiresome and boring ward round that feels like it will never end. I have the solution to the ennui induced by listening to someone drone on and on about the amylase, whether or not the TED stockings have been prescribed and the patient is wearing them, and worse; teaching rounds with no obvious point other than to make the teacher look smart. 

I have the solution to this problem right here. Ward Round Bingo, your very own print and use set of Bingo cards. No more texting, no more tweeting, no more surreptitiously trying to make your pager go off and thus escape. There is a heavy general surgery element but you can adapt for orthopaedics (NOF, FOOSH, ORIF), ENT (posterior nasal pack, post tonsillectomy bleed, tracheostomy problem, fish bone), general medicine (ward round exceeds 5 hours, increase statins, dual antiplatelets, Guillan Barré). What fun! 

Teaching is not about me 

Teaching is not about me 

Something has occurred to me recently, something that should have occurred to me years ago, and it’s that the teaching sessions I deliver are not about me. It may sound terribly self absorbed (it’s a flaw of mine) but for the last near 20 years I’ve been worrying about what I was going to say and how I was going to say it. Wrong! God what a vain and stupid cow I am. It’s about what they are going to learn and how they are going to learn it. 

Recently I’ve learnt the basics of how to teach and I can’t stop proselytising away about learning objectives and types of learners. It culminated in a session this afternoon (impromtu) in endoscopy when the nurses said at the end “that was great, what a brilliant teaching session, I’ve learned a lot too and how you did it was so clever”. I could not have been happier. 

I had one student and then an hour later I had two. I had decided the learning objectives for student 1 when he came in and we were making progress through the three objectives and then  when student 2 came I made student 1 teach student 2 what he’d learned; thus consolidating 1’s learning and freeing me up to do the paperwork.  Rather than me getting in a pickle about the pharmacology of buscopan, a distant and vague memory, we focused on just a few things and we did it well and when we finished they had learned something. It’s genius, and of course very obvious to people who know how. I’ve recently been criticised for my affection for the University’s “Teachometer” (not it’s actual name), as time spent teaching is not an measure of quality. I’m now on a one woman mission to make my teaching time quality time. 

Freeing myself from the terrible sense of fear that I might not know enough about the subject and therefore not be worthy of delivering teaching has been a long time coming. We filmed some of  a course we delivered locally and part of it involved me delivering a small group session. I have realised several things; I have a weird teacher voice, much quieter and softer than my usual speaking voice, I am not as fat as I think I am and nobody knew when I got the order wrong. 

In my perfectionist mind I had planned on saying things in a particular order but on the day, I didn’t, and despite my heart rate rising to 180 and feeling distraught at my failure, it was not at all apparent and didn’t seem like it was a disaster at all. This has helped me considerably to relax and enjoy my teaching because nobody but me knows what I am going to say and when. 

The observation that I get a gentler voice is not because teaching is anything like parenting, Mummy Me these days is a harassed and often shouting individual with little patience. I think it’s because I feel nervous and unsure, although fortuitously this is not how I come across and if I can project a bit more and change the tone back to my normal then it will seem more genuine. 

Anyway, now that I know that it isn’t about me I’m much less likely to get myself in a state mid lecture thinking I’ve ruined everything if I cock up my running order. Having the focus on them rather than me, so simple and so obvious, maybe that’s why nobody told me? 

I have lots of teaching to do this week and now that I am combining enthusiasm with some knowledge, theory and skills it might just be good quality. Can’t wait for the feedback/happyforms…but are they the right measure? Probably not but I’m excited nonetheless! 

Practice makes perfect

I love this quote, dished out today by one of my children’s music teachers, but it applies to Grade 3 piano as much as it does to surgery or any skill. There are many scientific papers and masses of anecdotal evidence that frequent practice of a skill leads to improved performance. I watch junior trainees practicing and learning and they quit far too early. Many of them can’t tie knots and they don’t understand that the only way to get good at it is to do it thousands of times. 

As a medical student I decorated every mug in my flat with long tails of black, silk, braided, surgical knots. When I was in theatre I would open and close clips and scissors with my non dominant hand endlessly, to practice being slick and good. 

When I tell them this, that I took scissors and clips and out of date surgical ties home to practice on all the time they look at me like I am mad. I had no shame about my desperation to be good, I wanted to impress my trainers and do well and getting a job  depended on me being good with my hands. I was in a constant state of preparation for the moment I would get to tie a knot, I was terrified of forgetting how to do it so I kept on doing it. 

There needs to be a shift in the mindset of surgical trainers and trainees that practice in simulated environments (especially crap ones like your commute or your kitchen)  is very much worth doing. For a start, it works, but new recruits also need to practice and prepare in a way that my generation did not do. I had a one in four on call rota as an SHO and a 70 or 80 hour week was standard. I had more learning opportunities than hot meals during those years but still sat for hours with little cuts on my fingers from tying so many knots. 

Another lesson I have learned, from my own amateurish sporting efforts, is that you seldom perform better than you practice. I can’t run a sub 48 minute 10k under the best of conditions, I won’t do so the next time I race one on a hilly course on a windy day. If you can tie a perfect knot sitting down in your kitchen then great; but can you do it with me watching, the nurse watching, on an actual vessel, standing in an awkward position down a deep, dark hole? 

Finding your surgical persona 

Finding your surgical persona 

“Work me” is not the same as “home me”, but both these people are true and genuine people. Many of my colleagues are the same at all times and have the same demeanour and seriousness about wrapping a birthday gift as they do about a laparotomy, but that wouldn’t work for me sadly and much like I have separate clothes for work and home I have had to separate out some of my behaviours. 

Being “fake” is hugely unpopular amongst people nowadays and that you might not be being true to your authentic self is a crime in the eyes of modern magazines for women and widely disparaged in society in general. I disagree, I have to have a professional persona in order to make people feel I am in control. Leadership of the team (despite the anaesthetists thinking they are the leader)  and taking responsibility for difficult decisions is part of my job. The real me, when left alone and unobserved, likes lying on the couch in ill fitting clothes, texting people and swearing. Real me is a dreadful person, with a smutty and childish sense of humour who prevaricates endlessly and can waste hours of time achieving nothing. 

At a friends last weekend I was drinking wine and chatting about nonsense when someone suddenly wanted medical advice. I immediately switched into doctor mode and everyone was amused at the change that came over me when faced with a serious question. I don’t have a problem with this split personality, I have worked out a way of being “me” but being professional. 

I’ve complained before about irritating altricial people who are seemingly born consultants and arrive at medical school with the gravitas and seriousness of  a professor. They don’t want to laugh and giggle and have silly games with their colleagues; they fascinate me in a way because I am so easily distracted and diverted from what I’m meant to do by the slightest bit of nonsense and novelty and find it makes the day more enjoyable. And as a recently personality profile has told me, I need to be amused and constantly stimulated in order to do any work. 

Finding the balance between being yourself and being a professional takes time and trial and error. I have spent lots of time behaving like other people I admire or was in awe of. In this way, mentors are hugely important, but watching people do things you don’t like is just as valuable as those you do wish to emulate. 

You put on clothes to make you look like the professional that you are expected to be and there comes a degree of professionalism when I walk in the door of Bighospital wearing my work clothes. 

Some people erroneously assume that to be treated as a professional you cannot be called by your first name. None of the scrub staff and only a very few, new, junior nurses call me Mrs KBW and they are corrected immediately. I am on first name terms with everyone and it’s only with patients that I will introduce myself with title and surname and I don’t hugely mind if they go on to call me by my first name. 

I’m not a nurse because I didn’t want to be a nurse, I wanted to do this. A nurse is a nurse because they wanted to be a nurse. It doesn’t fit with my philosophy on life to assume that they are nurses because they couldn’t be doctors or that being the surgeon makes me better in any way. I have a leadership role and decision making falls to me but we are a team and we need every member of the team, all are important. The NHS is not the army, or the police, we are a team. We are the public’s servants,  all working to the same goal, I absolutely abhor the idea that one of us in the team thinks that they are better than any other member. 

My surgical persona has not changed with moving from trainee to the boss, I’ve been warned not to develop new consultantitis (seemingly decent registrars lose the plot with their new role and start demanding things and having tantrums) but it really isn’t in me to behave like that. I genuinely have affection and respect for my colleagues, they are mostly brilliant and a pleasure to work with.

We have to move away from thinking that the way (men) of between 55 and 65 conduct themselves is the way to behave as a consultant. They are probably copying how their bosses behaved 40 years ago when they were my age and that is far from where society and teamworking and patients are now. 

I am as professional and credible and competent as any man in a bad suit and college tie combo and I am no longer apologetic for being nothing like that. It has taken a long time to reach this conclusion and have that degree of confidence and I wish I’d realised it sooner. 

Some people think that being professional is about what people call you, it isn’t. It’s how you behave, how you treat other people, how you operate, how you treat your patients, how you speak to colleagues. Respect is earned and not asked for and not wanting to be called by your first name by adult colleagues whose assistance and cooperation your job depends on is totally fucking weird.