This is my church, this is where I heal my hurts

This is my church, this is where I heal my hurts

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God is a DJ so the song goes, not so in Bighospital where God is the NHS. The faith that patients and their relatives place in my colleagues, in me and in the institution is exactly that, blind faith. I have lost count of the number of times people have said “I know that we are in the best hands” when in fact they don’t know this at all. Sometimes they are in far from the best hands and if only they had perforated their colon yesterday when the Professor of colorectal surgery was on call they would be in with a much better chance of coming out of this alive.

Nobody questions us though, they don’t ask if we have done lots of these, they assume we are the best person for the job. They nod and agree when I tell them that their father won’t survive an operation or that I must operate immediately on their pregnant wife. Like the Catholic faithful they accept that this is the word and thanks be to God and the NHS.

I wouldn’t be so accepting, so gratefully unquestioning. My only experience with the NHS as a patient is having children and I was under the best obstetrician in the hospital (as all doctors in Bighospital are) not that he was there when they were hauled out or flew out of me; that was the midwives and a nervous registrar on call for the one that needed some help. However, if I had been for an elective caesarean he would have been my choice.

Not many priests encourage their congregation to question the faith, but that is what patients should do if they want the best and most appropriate care for themselves.

The painting is by Salvador Dali, it hangs in the Kelvingrove Art Gallery in Glasgow.

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Never events

A never event is what we call a complete and utter fuck up of almost unimaginable proportions. It is chopping off the wrong leg, giving someone HIV infected blood or doing the wrong operation on a patient. We have systems in place to protect us from never events, and thankfully we don’t get many of them. What we do get is “can you believe it” events. I don’t want to list Bighospital’s department of general surgery recent fuck ups (who knows who could be reading this) but there tends to be one every few months that make you put both hands on your head and emit a pained “no, my god, he didn’t”.

One such thing happened recently in Bighospital, an operation I had assisted at and done absolutely bugger all of, other than close the skin. The fuck up has involved inadvertently suturing in a something (let’s say it is a drain although it isn’t ) and it could not be removed. So the patient had to go back to theatre to have the something removed, a quick procedure but unnecessary had my boss not got this thing stuck.

I wasn’t doing the operation, I am familiar with it but it was the first time I had operated with this particular surgeon and he did it differently to my other bosses. Infuriatingly, he has put me down on the operation note as the surgeon who has done this operation. I did nothing, apart from some skin sutures and holding the camera, he did it all.

He didn’t know that there would be a complication but he wanted to seem to everyone like he was Mr Cool, letting me do this more complex way of dealing with a simple problem instead of doing it himself. A lie in other words. I’ve learnt a lesson, which is to check every op note this guy writes and make sure I am not credited with an operation I haven’t done. My log book is marvellous anyway, I don’t need to vajazzle it.

So now, it looks to the world like I am the muppet who caused this “oh my Gosh, no, she didn’t” event. Grrrrr.IMG_0862.PNG

Intervene before your patient is moribund

If I could sum up the general theme of how I run my on call it would be this “I try to avoid death and major complications by prompt and proactive investigation and management of my patients”. Another way of saying this, which sprung more readily to my mouth on Saturday night was “I am not in the fucking business of letting Grannies bleed to death before I will get a CT angiogram” (yes, those radiologists again). And so, I found myself in the CT scanner with somebody’s Granny who had bled 1500ml of blood out of her bottom over the last 3 hours and a CT scan that revealed that the bleeding had now stopped.

The radiologist was angry! Angry that she was no longer bleeding to death and that her platelets and clotting cascade had finally mobilised themselves to form a clot and she was, for now, out of the woods.

These guys have a weird way of looking at things, I had a relieved family and a stable patient and felt that this was a good outcome. He felt he had done “an unnecessary CT” and I should have let her bleed much more before getting her scanned.

When I requested the CT (it took over an hour for them to get organised) she had bled from a starting haemoglobin of 81g/dl as she had bled at home and gone from her usual 11 to 81. I had given her 6 units of blood over 2 days and we now had an Hb of 76g/dl. An octogenarian cannot tolerate this sort of blood loss for very long, they fall off their perch and die.

He and I agreed to disagree, I’m not sure if he has a Granny, but if his Granny was on her way down a slippery slope he’d no doubt want her rescued.

I understand that many people become radiologists because they don’t want to be up all night (like me), don’t want direct patient contact, don’t want ownership of patients; they want a 9 to 5 controllable life. The deal with that life of radiology is that they are a service speciality, it’s my patient, not theirs, I am responsible for the proper care and ultimately for the life of this person.

In order to do that job properly, I will occasionally request a CT that is negative because that’s the nature of trying to do a good job and not miss anything.

Mrs Granny is stable and has not rebled, she is happy so are her family. I have emailed Dr Darkness a paper on managing bleeding in the elderly, which he won’t read, but it makes the point that modern management of bleeding involves avoiding near death inducing levels of hypovolaemia and anaemia.

If you’re going to become a radiologist there is an element of accepting that it is our patient, our call. We’ll take your advice and are happy to do so, we value your contribution hugely.

Not all of you are like this colleague of course, I have my favourites who are truly great and help me out immensely and I value their expertise and opinion. 

Nobody should ever say that a patient that stops bleeding and is no longer going to die (for now) was a waste of his time.