Medical Musings – Reflecting on my first job as a doctor.

(This was supposed to be published in August, but it is now September. I guess that missing non-medical deadlines is often the nature of a medical job.)

August is a month that holds a new significance for me.

In August 2018, I and others flew the coop of medical school to start working in the real medical world. Now, in August 2019, my colleagues and I might briefly pause to look over our shoulders at the distances which we have covered. It seems that there are only split-seconds to steal a glance of reflection, before many of the junior trainees of the medical profession take their next steps into new roles, in new teams, in new jobs and in new locations. I am attempting to press pause to steal a few glances more. 

General Surgery/ Colorectal (August-December 2018)

Classic drugs:

Co-amoxiclav, IV/PO morphine, lactulose and senna.

A day in the life (Not on-call):

An early arrival to the ward allowed a rapid check of the patients, to organise notes and shuffle our lists of patient details. We’d cram this in before the registrar arrived, who was usually early and anxious to get to theatre.

Then followed a blisteringly fast ward round with the surgical registrar, juniors hurrying in the registrar’s wake while carrying a stack of patient notes. We would burst through the curtains into a patient’s bay, read out the observations and blood tests, etch a hieroglyph of a hexagonal abdomen with lines, dashes and crosses into the page, then scribble any jobs for the day onto a crumpled list before departing through another set of curtains.

In the moment, the nurses must have thought our chaos was hilarious (before the tornado passes and the dust, papers and notes settled and the clean-up of re-siting misplaced notes and of recovering disorganised note trollies began). 

After the ward round, there would be a race to book the day’s imaging scans with the radiology department, with the surgical team vying for a head start against the emergency department, the intensive care unit and the medical teams.

After this rapid radiology run, the pace of surgical life quickly decelerated as we would head to “doctors’ mess” for a morning break. Over a cup of tea and a biscuit, the jobs we picked up from ward-round were divided easily, however, the conquering would take us late into the afternoon and evening. If we were well staffed and the jobs were few, perhaps we could attend theatre to view and help the day’s operations. 

The greatest clinical challenges were the acutely ill patients who had not, for many reasons, been surgically fixed yet. There were post-operative complications. Patients could end up in ITU. Largely, however, the job of a surgical junior is to be a logistician – organising scans and blood tests to line up a patient for the main event of theatre. In retrospect, it was a busy but simple life. 

On-calls were a different story. 

Job Highlights:

• Surgical post-ward round coffee in the mess.
• Wearing scrubs (And hence not needing to do laundry or iron clothes).
• Embracing the privilege to see incredible sights, such as open abdomens or organ transplants, when assisting with operations in theatre.
• Being hands-on with a needle and suture, scalpel, forceps, cannula and catheter.

Sad patient highlights:

I remember caring for a middle-aged man with metastatic renal carcinoma in the last weeks of his life.

I would check in with him daily while taking regular blood tests to monitor his renal function. We would chat about inanely normal things such as the audiobook he was constantly chasing the ending of, or the bands he liked to listen to, as if we could blind ourselves to the greater reality of his situation.

It seemed appropriate but paradoxical to ask, while jabbing him with needles to monitor his renal function, whether we were keeping on top of his painkiller needs. He dealt with the entire experience stoically.

As his disease progressed and his kidneys became repeatedly blocked off, I remember running around the hospital on the weekend, roping in radiologists and nurses to facilitate a last minute radiographically inserted nephrostomy for palliative reasons.

Soon enough it will be one year since our conversations. I don’t remember if he had many visitors or family, but he had good nursing staff and a frantic F1 doctor trying to help him.  His condition was dire but he passed away quickly, which may have been the kindest outcome. I hope he felt cared for when it happened.

Happy patient highlights:

A family man was admitted with searing central abdominal pain following a summer holiday season of too much booze and too much food. His amylase was raised and his CT showed retroperitoneal inflammation in the area of the pancreas. 

Inflammation of the pancreas is a nasty thing – after his admission to the ward he placed under strict instruction to take in nothing but water for over 2 weeks, being kept ‘nil by mouth’. For a man who liked his food, this was a different type of agony in comparison to the pain produced by his inflamed pancreas. 

Pancreatic pain, however, was a recurrent issue and it was challenging to keep on top of his analgesia needs. He described it as a constant gnawing, punctuated by sharp spasms and stabs that went through his stomach and his back. His damaged pancreas grumbled on for weeks, improving and worsening from one day to the next.The non-linearity of his recovery was frustrating, and scary. He would show improvements across a week, before tumbling downwards across an afternoon. Across the duration of his admission we performed multiple scans to image his pancreas, together showing gradual dissolution of part of his pancreas with subsequent cystic changes. When he did start eating, he had 10 days of steatorrhoea (google it, or don’t) despite the enzyme-replacement stuff we had him on. 

I learned a lot from his mentality. On his admission he didn’t seem like the most mentally tough individual. On reflection, I now have a greater level of respect and sympathy – being an inpatient for a prolonged period of time, lying in bed with a stable but potentially fatal condition, must be psychological hell. Despite all the crap he went through, it was fantastic to get him back home. I didn’t see him again, which is probably a good thing. 

Entertaining patient highlights:

• Amazement at the things people put up their bottoms! (That we then have to remove). 
• Having a post-operative patient develop ileus and urinary retention on the same night, requiring almost simultaneous NG tube placement and catheterisation.
  This is certainly one way to build a concrete doctor-patient relationship that they don’t teach you at communication skills sessions at medical school. 

Take-aways:

1. Book scans early.
2. Get good at cannulas.
3. Know the doses for analgesia and anti-emetics.
4. Buy comfortable shoes.
5. Follow consultant advice: No abdominal examination is complete without a PR. 

Thanks for reading!

Check out my second job – Part 2- Respiratory Medicine.

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The Rumps, near Polzeath, Cornwall, on one of the escapes I took in the ‘zero’ days following a batch of night shifts.