Respiratory Medicine – (December 2018 – April 2019)
Medicine over winter is always going to be difficult. There is a seasonal pattern to hospital admissions across the year; the term ‘winter pressures’ describes the high numbers of patients with pneumonias, trauma and other illnesses associated with darker and colder days.
Across this winter period from December to April, I worked on the Respiratory Ward, a world of weird and wonderful lung diseases, meeting patients affected by auto-immune conditions to infective pathogens. The majority of the patients I looked after, however, were people with Chronic Obstructive Pulmonary Disease (COPD), a degenerative lung disease contributed to by environmental and lifestyle pollutants, such as smoking.
It might have been the Winter season, but I found this job quite sad. I learned a lot of medicine, but I also learned a lot about people, how they live, the emotions they feel. In comparison to my surgical job in the summer, I also learned a lot more about how people die. This experience is tragic and very ‘Being Mortal’ and in some ways I was reluctant to write about it. On the other hand, I’ve learned that death is part of the reality of life and on reflection I have taken steps towards better understanding the human condition. I know that other junior doctors and healthcare professionals will likely have had similar experiences.
I talk about patients and their loved ones in this blog. My sister suggested to me that perhaps it is impossible to observe people’s emotional strengths in situations of adversity without highlighting my own removal from their situation – that observations from my perspective as a fly on the wall cannot recognise the deeper emotional currents that each of these people hide beneath their surfaces. I am certainly very lucky to be in this position of observation and it is very easy for me to reflect on the difficulties of ill health and the stoicism of these patients without too much further concern – after all, I am not the one experiencing it.
Personally, I am glad that I do not experience the emotional and physical pain of all of the patients I see. Doctors see so many patients in a day that the demands of empathy can be overwhelming and contribute to ‘burnout’. We do take away a residue from each encounter with a patient, which I had previously thought we would be resistant to or be blind to. I think this blog shows that actually, when I have actually thought about our encounters, the patients that I had seen as part of the job have left a deeper impression.
In answer to my sister – these observations are taken from a privileged position but are validated by subsequent reflection. Whether I like it or not, the emotions and lessons learned when meeting patients will be inevitably carried forward into those people I see next. The ability to reflect gives the residue of an observation more colour and depth.
So, hold on tight and get ready to enter the world of a FY1 junior doctor’s medical job.
‘Amox and Doxy’, salbutamol and ipratropium nebulisers, oxygen.
A Day In The Life:
The doctors filter onto the ward to start at 0900 – what a luxury! Just like any other ward, we’d meet, do a board-round (which deserves its own blog post), do a ward round, complete jobs and make moves to fix and discharge patients.
When home-time came, we’d round up the loose ends, relay these to the evening on-call team and close our computers and notes to start again in the morning. Ward work had a straight forward structure and could be exciting and busy, or slow and, erm, less busy.
Whereas the surgery ward-rounds were a frantic whirlwind, they at least were complete in an hour or ninety minutes. Surgical ward rounds were then followed by a job list that could be conquered steadily across the afternoon.
In this new medical job, ward rounds are more comparable to a marathon. Unlike surgery, where the ‘fixing’ is done by senior trainees and consultants, medical patients will have much of their tinkering from juniors and seniors alike. Surgical patients are fixed in theatre. Medical patients are fixed on the ward, during ward-round, by adjustments of medications and therapies. Medical ward rounds are like conducting minor surgeries on every patient, every day. Change this beta-blocker, titrate this diuretic, book this scan, drain that chest. These ward rounds take some time!
Another difference was in the profile of a patient’s journey through hospital. When a surgical patient is admitted with an infected gallbladder or a ruptured colon, they are in a very bad way. They usually get better, quite quickly, after ‘definitive surgical management’ – Let’s cut the offending bit out.
When the problem is removed, the patient’s physiology soon recovers to a normal state and they’re free to get on with life. Medical patients, however, can be sick when they are admitted and can stay sick for a while. There often isn’t an ‘offending part’ to be removed – If you removed the lungs of a COPD patient, you would have solved the problem but, unfortunately, the patient would be dead (as heart lung transplants are for the few).
So, medical management is about slow additions and adjustments of drugs to coax a patient’s physiology back into a functional state – so that they achieve a new homeostasis of their chronic disease and can be returned to the normal rhythm of life again. Of course, there are exceptions – such as being acutely ill with a pneumonia or endocarditis – but even then, a course of antibiotics stretching from a week to months might be on the cards.
All in all – patients tend to stay in the hospital longer when they are suffering from chronic medical problems. The ward rounds are longer, more physiological fiddling is done, and often, the end result is a slow progression from a physiological state of ‘not coping’ to a state of ‘functioning’, rather than from progressing from ‘sickness to health’.
- 9AM-5PM. I haven’t been able to write much this year in comparison to during my time at medical school, but having some time free in the morning allowed me to write this blog!
- I also had enough time after work to be able to train for a 70.3 triathlon without having to sacrifice too much other stuff, or importantly, sleep. I am a believer in the phrase ‘time is the most valuable non-renewable resource’ and this belief has been heavily reinforced this year.
- I found medical on-calls challenging and exciting, a varied buffet of medical complaints with a sharp learning curve.
- Our doctor’s office had a cafetiere that I could use to make coffee to sip while writing discharge summaries and other administrative work. Never had I typed so fast.
Sad Patient Highlights:
Motor Neurone Disease (MND) is a terrible disease.
I think I’ll remember this woman for many years to come. Her disease presented in a subtle way – with a change in voice, an insidious dry cough and facial expressions that gradually became faded, slower and more mask-like. We stumbled around the true diagnosis as our investigations repeatedly disproved theory after theory.
MND was at the back of our minds from the beginning, but Occam’s razor kept pushing it further back on our lists. The presentation was too atypical, too subtle – there were other conditions that were more likely.
We probably investigated every other cause of this woman’s symptoms before we were left with no other conditions to pursue. We’d done everything, but it was too late – a diagnosis settled upon via a path of exclusion, of a condition for which there are only experimental treatments available and no definitive cure. A diagnosis as an alternative term for death.
I look back on this grimly. It is incredibly hard to keep a patient in hospital for investigations and treatments when the options of treatable diagnoses continues to dwindle while the potential for the incurable increases. The daily ward round was fraught with fear – fear felt by the patient of a fate uncertain, and fear by the medical team of diagnoses missed, of failing to calm the patient’s anxious pain, of failing in our responsibility of cure and care.
We settled on the diagnosis finally, triumphantly, sadly. Triumph for what?
Doctors diagnose to be able to cure – so what do we do and how do we feel when we have heavily invested in investigations to find that we cannot complete our mission to help and heal?
How does the patient feel when she realises that despite the best of modern science’s efforts, she has fallen through the cracks of our knowledge?
Inevitably, there was a breakdown in communication and emotion because of the fundamental differences in the roles between the patient and the doctor. Patients want a cure to resume their normal health and life. Doctors want to diagnose and cure because it’s engrained into them and satisfies them.
When the two parties cannot meet in the middle, finding the ‘cure’, the relationship can change from trust to mistrust, belief to doubt, tenacity to apathy. One or both parties might give up. Both parties leave the relationship with some question unanswered or need unaddressed. In this case, the diagnosis sealed the management plan. Medical hope was withdrawn and the only next step was to confront mortality. We expedited a fast-track, compassionate discharge to return home to her family to pass away in peace.
I’ll start by saying that I am not sure how I should have dealt with that experience and that this reflection is incomplete. I have a great respect for the patient and how she dealt with her time in hospital. It must have been agonisingly difficult to be at the mercy of others, to have maintained hope against an infinite number of uncertainties. It made me realise how vulnerable it can be to be a patient, how respected doctors can be, and how much medical and emotional responsibility the role of doctor has to command.
We exhausted the medical avenues and did the best diagnostic job we could – I can’t criticise the medicine. With hindsight, however, I wish I could have been more emotionally sensitive to address all of her fears and concerns and anxieties – but in the moment, as a doctor with multiple things to do and a myriad of other problems to solve, it seemed impossible to even consider tackling the problem of approaching death. One day I might be in her position. Before then, I will probably see more patients like her. I hope that in the future I will navigate these situations with an awareness of humanity.
Learning From Ward Rounds and COPD:
Running my own ward-rounds and ‘owning’ a section of the ward was incredibly rewarding. Sure, it was occasionally tedious to see the same patients every day, especially when I was tired or had another stressor such as the mandatory ‘e-portfolio’ or some external life event leaning on my mind. Most of the time, however, I found enjoyment in the human side of medicine. An admission for an exacerbation of COPD will likely settle with oxygen supplementation, physiotherapy, good nursing care and some drugs such as antibiotics and nebulisers. These ingredients are startlingly few. The bulk of the healing recipe is time, and a lot of time lends itself well to conversation and building relationships.
‘The art of medicine consists of amusing the patient while nature cures the disease.’Voltaire
I won’t forget the elderly man who had previously lost a leg to diabetic vascular disease. Despite falling towards the brink of death leading to his 6 week admission, he just couldn’t stop smoking. Even after three ‘Medical Emergency Team’ calls (A rush of doctors, extra oxygen, the emergency trolley, the defibrillator at the ready) for three separate near-death exacerbations of his lung disease, he would still not stop smoking.
His daughter would push him with his wheelchair down to the hospital entrance to have a cigarette and a chocolate bar, before returning to have his midday antibiotics and inhaled salbutamol nebulisers.
He finally got out of hospital as we entered the spring – he had survived another winter. Every admission is a memento mori. I hope he has made it to his villa in the Canary Islands to soak up some sun. The Vitamin D will surely do him good.
Learning From Marriages:
Neither will I forget the old couple of Londoners, married at 18 and 16. They were East-Enders who made good, living in London in the 1940s and ‘50s before moving out to the West Country for a quieter life.
When I met them, she was stuck in a hospital bed and sick with COPD, her purple-tinted hair hiding yet betraying the yellow tinge of a history of smoking. He would visit every day in blazer, trousers, a straight back and stiff upper lip, always proper, always a gentleman. Always with his jaunty East London accent.
I would check in daily.
‘How’s the cough? How’s the breathing? Any wheeze?’
We played whack-a-mole with infections, giving oral, intravenous and nebulised antibiotics in different formulations, in constant pursuit of the latest pathogen grown on her sputum samples.
We’d feed her and keep her hydration levels topped up with intravenous fluids. Despite our standard medical protocols of care, a short hospital stay became a long one, but without much progression in her health.
Small wins were had daily, such as her having the energy to independently eat some food or having a particularly good physiotherapy session. Despite all the progress, setbacks seemed to hit almost weekly.
A theme of my reflections is the strength I see in patients who are in hospital for a long time. She is no exception. I find that the patients I meet of her generation are stoic and resilient like steel. They accept the load that’s placed on them, flexing to accommodate the stress of it all. She was dedicated.
I remember telling her that muscle mass and strength would help her get out of hospital. I’d say ‘do more physio!’ to which she’d reply by kicking her legs around the bed and by squeezing her stress ball, every extra repetition hoping to strengthen her hold on life.
She’d complain she had no appetite. I’d suggest to her that if she just ate the protein on the plate, we’d sneak in some extra ice-cream later.
Who knew if it worked, but it kept her going. She didn’t give up.
Her husband’s dedication was unfaltering. He accompanied her throughout the hospital journey and then through her discharge to a rehabilitation facility. This was followed by re-admission to the hospital and then perhaps through the same journey again.
I remember bumping into the two of them after I had changed jobs to another department, the pair sitting with some friends outside of the front of the hospital entrance where the pavement leads down to the front carpark. They were sitting on the picnic benches and enjoying the afternoon sun.
She looked pale and anaemic- a product of chronic disease and prolonged hospital admission. He had a bronzed tan, probably from working hard to fix up the garden and the house in his perpetual hope that she would return home again soon. I left the hospital soon after – another story finishing without an ending.
Fun Patient Highlights:
Winter pressures are morose and stressful, right?
In amongst the bays of coughing patients with COPD, we had a new arrival to the ward. He had been wheeled up to us on a trolley just like the other patients. He was not panting or puffing, nor was he tied to an oxygen cylinder via a facemask. He didn’t look sick.
Instead, he was sitting upright, grinning a toothless smile, curly grey hair erupting in all directions like springs. His arms would reach out, waving at the staff and trying to shake our hands.
‘Good morning doctor! ‘Hello, nurse! Hello, all!’
Let’s call him Arnie. He wasn’t psychotic or delirious. He just was happy. He was overjoyed to be alive.
He was in his late 70s. Having attended the respiratory clinic that week he had been diagnosed with a lung cancer that was deemed inoperable. Apart from this cancer, he was otherwise well. The cancer was large, approaching some of the major vessels in the chest. As a result, the tumour was very vascular – it had a very extensive blood supply to it. Arnie had been sent home after his diagnosis in clinic but had been soon re-admitted for observation after having coughed up some blood at home. With a known diagnosis of inoperable cancer, he was not admitted to have intensive management. Our plan was to re-scan him, see how the tumour had progressed, monitor the bleeding until it stopped and then to let him return to his life.
Being the ‘healthiest’ patient on a ward, with a ticket to leave, must be a boon! He would walk around in his underwear and a newspaper, walking into private rooms and between patient curtains.
He chatted with patients, receptionists, doctors, nurses, the public, or anyone else who had a moment to spare. His cheerfulness was exactly what a sick ward needed.
He didn’t care that his diagnosis was terminal. He didn’t care that he wouldn’t be here next week. He freely said that he had had a good life. His cancer was the real ticket out of here.
When he was discharged, he cheekily put his thumb to his nose and waggled his fingers. See ya!
- Wash your hands.
- You might have the strongest microbiome when you’re outside the hospital, but when you’re at work, run down, sleep deprived – Take steps to look after yourself.
- Be more human, even when you’re feeling busy.
- When the days are short in the winter, spend time on the weekend getting some sunlight.
- Take time to reflect – stories with patients enrich the job.
- Be more like Arnie. Life is short.
Thanks for reading! If you haven’t, check out Part 1 – my surgical job.