A Year in the Life: September 2020-2021

I’ve updated this website with disappointing infrequency during the past 12 months.

I had great expectations for my writing performance in the period following the Foundation programme (termed F3, F4, F(n+1)). For non UK-medics, I explained F3+ in my blog written at a similar time last year, but for a recap, this period is a potentially infinite duration between formal training jobs in the UK’s medical system, whereby medical employment is largely chosen by the individual to suit their current and/or future career and lifestyle requirements. For the first time in many years, life is not planned by a school timetable, a university curriculum or a hospital rota. Aside from the usual constraints of finances and other obligations, this is the closest that medics can get to ‘freedom’.

I had imagined ample time free for projects and naturally, increased inspiration to write for the internet e.g silly interests such as the microbiome and healthcare workers, for instance, or blood glucose monitoring and my morning porridge.

On reflection, I feel that I’ve been busier this year than previously – perhaps all this extra freedom carries a hidden demand of having to organise ones own life, or perhaps working outside the bounds of a job plan allows one to go ‘all in’ with self-organised projects, leaving little time for anything else.

In fact, I’ve written a lot this year (possibly the most writing I’ve ever chosen to do), but little of this contributed to this blog. That’s going to change (and I mean it this time). To kick off, here is some writing and some photos – published for your interest and my memories for when I’m old – what did I do between Sept 2020-2021?

Orthogeriatrics. The “OG’s”.

For the first five months of the year, I worked as a ‘locum’ doctor to help staff a rota in one of my previous hospitals. I worked in Orthogeriatrics, a peri-operative medical sub-specialty that focuses on optimising the health of (usually elderly) patients in the time surrounding large orthopaedic operations. Orthogeriatrics usually encompasses a relatively small population (elderly men and women aged >~65 years who have sustained a fractured neck of femur (‘NOF’)), but has a substantial workload for multiple reasons.

Hospitals see all sorts of traumatic injuries, which are often associated with younger people, violence and road traffic accidents. Standard ‘Trauma’ care for these cases involves highly standardised protocols for stabilising and assessing patients in the emergency department, with blood tests, vital signs and CT imaging being performed under the watch of a ‘Trauma Team Leader’ and a ticking clock. On the other hand, orthogeriatrics focuses on ‘Silver Trauma’. These older patients can sustain serious and life-threatening, but subtle, injuries through seemingly benign accidents, for example, a fall from standing height. There may be no mangled limb or bleeding vessel to alert the emergency staff of something seriously amiss. Thus, after trauma, the elderly population may be at greater risk of delayed investigations and treatments, leading to poorer outcomes. Dedicated orthogeriatric ‘Silver Trauma’ teams can pick up these patients soon after admission with the intention to improve care and outcomes for this distinct trauma population.

In fact, road-traffic trauma isn’t that common, but there is a steady stream of older members of our society falling and causing themselves harm. Silver trauma makes up about 50% of trauma cases seen in hospital, and this is set to increase as the population continues to age. We’re good at dealing with the exciting trauma from traffic accidents – but it’s about time we paid more attention to elderly trauma too.

Secondly, the likelihood of medical comorbidities (cognitive impairment, metabolic diseases (e.g. diabetes, impaired glucose tolerance) and other organ dysfunctions (kidney, heart, lung e.t.c.)) increases with age – making the passage of these individuals through the rocky waters of a serious orthopaedic operation and a long hospital stay a tricky one. Alterations of medications that worked fine in the community but are inappropriate for the current circumstances must be made. Optimising the homeostasis of components of an individual’s overall physiological state, such as heart function or fluid balance, may be required to make a patient ‘fit’ enough to survive an operation; although essential and lifesaving, surgery is experienced by the body as another physical ‘trauma’ with further tissue damage and bleeding, while we mustn’t forget the risks of general anaesthesia. After operations, elderly patients must recover from these multiple physiological insults, while trying not to accrue more – such as hospital acquired pneumonias, urinary tract infections, or delirium. Then comes the challenge of musculoskeletal recovery and rehabilitation, facilitated by the individual’s will and mental state, nutritional support and physiotherapy. It sounds complex and it is.

In summary, this job was a win-win. It was a win for the hospital I worked in as they gained a doctor to fill a gap in the rota to allow a busy department to continue ticking over across winter, a dangerous season of slippery pavements and icy porches. It was a big win for me as I could earn a bit more money than I would have earned as a foundation doctor while having relative flexibility to pick my hours and to complete my other projects, work in a good team, and still learn a good amount of often complex and multi-morbid peri-operative medicine.

“Van Life”

During these first months of the medical year I started hunting in the second-hand van market. By January, a van had been found to be ‘converted’ to have a bed, rudimentary cooking equipment, a fridge, storage for sports equipment and places to securely mount bikes inside the van. It’s messy, it’s very DIY and it smells of wetsuits, but it works. Let’s face it – No millennial career break or ‘F3’ would be truly complete without some aspect of ‘van life’, whether lived vicariously on Instagram or in reality.

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  A sliding drawer holds essential kit for adventures. A wooden extension attached to the rear seats allows a platform to be made when the seats are folded forward, forming a bed. Clever!

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  DIY bed platform. Drawer to come. Some wooden panels.

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  In use! I fixed some rails down onto the van floor to attach some fork mounts, allowing two bikes to be fastened width-ways. Space saving and secure!

In September 2020 I also started working with a full-time smart guy MD PhD Tommy Wood. One of my goals for the F3 year was to dip my toes into academia; a world running parallel with medicine and which medicine heavily relies on for progression of diagnostic abilities and treatments, but difficult to meaningfully enter and navigate within.

We have explored the topics of infant and elderly brain diseases and dietary polyunsaturated fatty acids (PUFAs). So far, we’ve got two papers cooking and a book chapter submitted, while I’ve accumulated some invaluable insight into what it *may* be like to portion more of my time into formal academia, as well as developing my ability to read for more than 5 minutes at a time.

This mention is merely a nod towards the work that had gone into these projects, which easily consumed as much of my ‘free time’ than a full time medical job would have. Academia is a hard life and I have constantly increasing respect for Dr Dr Wood’s cerebral volume and the density of his inter-neuronal connections. Hopefully, if all goes well and the papers are accepted for publication, we will add some interesting thoughts into the world – more than I can say for much of my other writing!

Here’s a quick break to mention this article’s sponsor:

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Intensive Care Medicine.

I started working in Intensive Care Medicine (ICM) in Bristol at the beginning of February. I joined the ICU during the second-wave of the UK’s Coronavirus pandemic, wore PPE and met many patients. I’m not sure what more to say about that.

I also saw some incredible medicine and some impossible combinations and sequelae of disease – An example may be an admission following a haemorraghic stroke, revealed to be due to cerebral septic emboli associated with endocarditis, with a significant threat of a concurrently expanding aortic root abscess. Say that again? These are all diseases that exist in their own right, but to suffer from the combination of these is outstandingly bad luck for the individual. The concern is for the patient, but these circumstances of pathology are amazing for me to observe as a doctor. Clinically, the amount of diagnostic work up, pharmacological and surgical treatments, interventional radiology input, constant physiological monitoring, nursing care and time needed to deal with clinical situations such as these is just mind-boggling – but is part of the routine of working in a ‘Unit’.

As an aside, I never got round to writing the third instalment of my reflections of being a F1 (One and Two) – the final rotation of which was also in ICM, albeit in a different hospital. Both experiences shared similar opportunities to see the triumphs and troubles of complex medical care and human relationships; the hardest fought battles I have seen are found in the journeys of ‘long-stay’ patients in Intensive Care. It’s impossible to convey the experiences of patients that are seen and felt by their clinicians without one being physically present on the Unit, but I’ll try to describe the reasons for their challenges.

Firstly, the reasons for admission are exceptional – exceptional trauma, complicated and serious injuries, but with enough luck to have survived long enough for emergency services and operations to act. Similarly, medical issues are at the extreme of the survivable spectrum. Catastrophic strokes with causes more sinister than ‘just’ cerebrovascular disease and narrowed blood supplies – the case above as an example. I have seen hidden dental infections that spread to eat away at spinal vertebrae, leading to vertebral collapse and severance of spinal cord to leave an individual’s body numb and paralysed from the neck down. Infections that spread from a sore throat to the muscle of the heart, leaving the heart unable to pump strongly and with a tendency to flick itself into fibrillatory rhythms. Respiratory failure and cardiorespiratory arrest due to an unknown neurological disease, apparently progressive, a race against time.

Secondly, because of these complexities, these patients easily become trapped in the web of medicine. The resolution of these injuries and illnesses require protracted courses of antibiotics or multiple operations but mainly need time. And, as with the orthogeriatric patients I described above, hospital admission produces its own risks. All this time makes ICU patients sitting ducks for complications. Pneumonias, produced by the very ventilator and intubating tube that provides essential oxygen and gas exchange to patients, threaten lives. Infections, delivered by the lines that are used to administer antibiotics, have mortality rates up to 25%. Mental health issues following traumatic events (admission to critical care is a bona fide traumatic event) can make even the most physiologically strong candidate apathetic and depressed in the face of a long recovery.

Exceptional illnesses. Therapies perhaps as demanding as the illnesses themselves. Physical impairments and disabilities. Constant threats of infection, organ dysfunction and death due to the very system that is trying to help them. After the initial storm settles and the patient wakes up, they then have to come to terms with all that’s happened, all they didn’t know, and all they have to deal with next. They might stay for weeks or months. It’s a big deal when we can get these people sat up in bed, eating real food or just ice cream, seeing people they love, or sitting outside the hospital entrance in their ICU bed on a sunny day.

The Intensive Care Unit (ICU) is a place for doctors with an appetite for complexity, an understanding of risk, and who know the difference between when to think and when to act. They’ve got to be sharp in the moments that matter. They also have to have a softer side, a considerate and communicable side to deal with all the squishy human aspects of medicine, to empathise with the patient whose back is against the wall, or the family who don’t know where to look when visiting a loved one ‘lined up’ with tubes and beeping machines.

For clinicians, the intensity of this clinician-patient relationship is absurd – requiring full investment from ‘go’ with an evolution of understanding of the individual as they emerge from their illness. It’s hard not to be touched by the vulnerability shown by other humans. When they go home, we rarely see them again.

I know these qualities are represented by doctors within all medical specialties, but I was so impressed by the work in the ICU.

Intensivists should start climbing.

Outside of the ICU, a few friends convinced me to try climbing in the great outdoors. With them, I’ve done one ‘winter mountaineering’ course (the snow didn’t turn up), one ‘trad’ climbing course and one climbing trip away in the Snowdonia national park in north Wales. At this point, I’ve got just enough knowledge to accidentally and unknowingly kill both you and me.  

I wanted to write a blog about climbing and ICM but I didn’t have time. These two fields are remarkably similar in their approach to getting stuff done and with approaching risk. The analogy starts with equipment – both depend heavily on specific equipment and the knowledge and ability of an operator to use the equipment correctly. If an intensivist knows they need a drug and an endotracheal tube but picks the wrong drug and a paediatric tube, they may have the right idea but the wrong kit. Likewise, if I picked up the right drug and the right tube, I’d be kitted out with no idea of actually what to do next. Panic ensues. Likewise, climbing requires specific equipment. Bought a non-waterproof rope to use in North Wales? Your rope will absorb water and become heavy. This extra weight is more to carry around, but also stretches the rope, eating into the elastic safety margin a climber relies on if they were to fall onto the rope. This means less dissipation of the shock at the end of the fall – resulting in either pain at the end of the rope, or a lot of pain at the bottom of a broken rope. Choosing a waterproof rope in wet environments is a better idea – as well as dialing down the correct material, diameter etc.

The analogy continues with equipment, too. Before we head up to the hills we check all our kit. Slings? Check. Harness? Check. Belay plate / rope / gear / helmet? Check. Car keys? Don’t forget the bloody car keys. (That’s another story). These are the basics needed to function.

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  Did I tie this on right? Check!

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It’s the same in ICM and anaesthetics. Proformas and checklists are placed to ensure that the right thing is done at the right time, every time. The number of checklists can be quite monotonous – Check the invasive lines trolley, the drugs bags, the emergency bags, the airway trolley, the video laryngoscope, whether you’ve peed, tied your shoe laces, check your own name etc.

Where it’s even more important is in critical situations. Even the most experienced intensivists pause before a ‘Rapid Sequence Induction’ (of anaesthesia) to run through the ‘Intubation Checklist’.

From the Difficult Airway Society.

And it has to be so – for while the consequences of neglecting Plans B, C and D are serious, forgetting something seemingly minor on the checklist can pose a dangerous hindrance later down the line when you really really need it.

When climbing, the consequence of leaving your rope at the van is that you walk back down the hill. That’s poor equipment admin. The consequence of not doing a buddy check (those pesky figure 8 knots), checking that carabiner screw-gates are closed, or communicating to each other ‘Safe!’/’That’s me!’ can be that one or both of you fall off the rock.

In fact, I think that the dependence on good equipment, rigorous checks and communication in critical situations makes climbing the mascot sport of critical care. I think it suits the personality and body habitus of these doctors far more than their common association of being cyclists or endurance types. With these analogies, the similarities stop at their common interests of physiology and shiny, expensive things. Climbing is more serious and consequential. Case made.

More fun stuff:

Combining medicine and sports, I learned about the physiology and physics of diving at the Diving Diseases Research Centre in Plymouth. This built and consolidated the learning I had previously had during my Extreme Physiology modules at medical school – people who voluntarily compress and decompress themselves are nuts, but I can see how decompression illness is an accepted risk to enter other worlds. More importantly for my current job, we covered diving-related medical emergencies and common medical conditions exacerbated or produced by spending time in pressurised environments – perhaps I’ll pluck the courage up to go diving or to assist those who want to go diving.

I took part in the Snowman Triathlon in August with a good friend, again in north Wales. We came 10^th and 11^th respectively (I won’t say who won out of the two of us). I wish I had more photos but really they would just show the suffering that occurred all day and for the following days. A gruelling course, this event finished with the ascent and descent of Moel Siabod– but it really finished with a pub dinner and some Snowdonian Purple Moose beers.

All these above previous events and activities were squeezed in around rotas, however, one of the greatest aspects of being a ‘F+’ working outside of a rota is the time provided – hence, it was great to be able to see my family more freely, to travel a bit more (when allowed) and even to go abroad to Scotland and France to see more family and friends.

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  Approaching Bealach na Bà on our way to the Applecross Inn for some micro-pub beer and seafood macaroni cheese.

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  Loch Lomond pulled out the stops in May.

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  Stealing a weekend away in The Gower, Wales.

And voila – that’s it.

I’m in a new part of the country, even further South West.

What’s next?