Shattered. Third consecutive day of on-calls at the birth centre. I’m afraid I have little to show for it. The logbook hangs limply at my side, the pages where my name is printed await signatures; surrogate markers of new found skills. Half asleep I slump against the wall and cast my mind back to the peripheral attachment from which I have not long returned. The old-school consultant’s mutterings are still fresh: “Medical education was different back then you see....you are dealt a tough hand nowadays.” I quite agree, it is Saturday.
Might it be said the clinical apprenticeship we know today is a shadow of its former self? Medical school was more a way of life, students lived in the hospital, they even had their laundry done for them. Incredulous, I could scarcely restrain a chuckle at the consultant’s stories of delivering babies while merely a student and how the dishing out of “character building” grillings by their seniors was de rigeur. Seldom am I plied with any such questions. Teaching is a rare commodity at times. Hours on a busy ward can bear little return. Frequently do I hear students barely a rotation into their clinical years, bemoan a woeful lack of attention. All recollection of the starry-eyed second year, romanced by anything remotely clinical, has evaporated like the morning dew.
“Make way, make way!...” cries a thin voice from the far reaches of the centre. A squeal of bed wheels. The newly crowned obs & gynae reg drives past the midwife station executing an impressive Tokyo drift into the corridor where I stand. Through the theatre doors opposite me he vanishes. I follow.
Major postpartum haemorrhage. A bevy of scrubs flit across the room in a live performance of the RCOG guidelines for obstetric haemorrhage. They resuscitate the women on the table, her clammy body flat across the carmine blotched sheets. ABC, intravenous access and a rapid two litres of Hartmann’s later, the bleeding can not be arrested by rubbing up contraction. Pharmacological measures: syntocinon and ergometrine preparations do not staunch the flow. Blood pressure still falling, I watch the consciousness slowly ebb from the woman’s eyes.
Then in a tone of voice, seemingly beyond his years, the reversely gowned anaesthetist clocks my badge and says, “Fetch me the carboprost.” I could feel an exercise in futility sprout as I gave an empty but ingratiating nod. “It’s hemabate....in the fridge” he continues. In the anaesthetic room I find the fridge and rummage blindly through. Thirty seconds later having discovered nothing but my general inadequacy, I crawl back into theatre. I was as good as useless though to my surprise the anaesthetist disappeared and returned with a vial. Handing me both it and a prepped syringe, he instructs me to inject intramuscularly into the woman’s thigh.
The most common cause of postpartum haemorrhage is uterine atony. Prostaglandin analogues like carboprost promote coordinated contractions of the body of the pregnant uterus. Constriction of the vessels by myometrial fibres within the uterine walls achieves postpartum haemostasis. This textbook definition does not quite echo my thoughts as I gingerly approach the operating table. Alarmingly I am unaware that aside from the usual side effects of the drug in my syringe; the nausea and vomiting, should the needle stray into a nearby vessel and its contents escape into the circulation, cardiovascular collapse might be the unfortunate result. Suddenly the anaesthetist’s dour expression as I inject now assumes some meaning. What a relief to see the woman’s vitals begin to stabilise.
As we wheel her into the recovery bay, the anaesthetist unleashes an onslaught of questions. Keen to redeem some lost pride, I can to varying degrees, resurrect long buried preclinical knowledge: basic pharmacology, transfusion-related complications, the importance of fresh frozen plasma. Although, the final threat of drawing the clotting cascade from memory is a challenge too far. Before long I am already being demonstrated the techniques of regional analgesia, why you should always aspirate before injecting lidocaine and thrust headlong into managing the most common adverse effects of epidurals.
To have thought I had been ready to retire home early on this Saturday morning had serendipity not played its part. A little persistence would have been just as effective. It’s the quality so easily overlooked in these apparently austere times of medical education. And not a single logbook signature gained. Oh the shame!
This blog post is a reproduction of an article published in the Medical Student Newspaper, February 2014 issue.
BOXING Day, 1.30am. “Are you the doctor on call?” I wrenched my reluctant brain from its REM state. “Yes.”
“I’m worried about my wife. She’s 16 weeks pregnant and very gassy.”
“Burping and farting. Smells terrible! It’s keeping us both awake. I’m worried it could be serious.”
By the time I ascertained that there were no sinister symptoms and that the likely culprit was the custard served with Christmas pudding (the patient was lactose intolerant), I was wide awake. My brain refused to power down for hours, as if out of spite for being so rudely aroused.
I have a confession to make. When the Australian Federal Government announced that it was planning to abolish after-hours practice incentive payments, I was delighted. I know, I know, I should have been outraged along with the rest of you. After all, the RACGP predicted that after-hours care would be decimated if incentives were removed. Comparisons were made with the revamp of the UK system in 2004, which led to 90% of the profession opting out of after-hours work. Much as I sympathised, I was secretly rubbing my hands together with selfish glee. Surely this would mean that our semi-rural practice would stop doing all of our own on-call and free me from my after-hours responsibilities?
I detest being on call. I loathe it with a passion completely out of proportion to the imposition it actually causes. I’m on call for the practice and our local hospital only once a week and the workload isn’t onerous. Middle-of-the-night calls aren’t all that frequent, but my sleep can be disturbed by their mere possibility, leaving me tired and cranky. If I’m forced suddenly into “brain on, work mode” by a phone call, I can kiss hours of precious slumber goodbye.
I love to sleep, but, as with drawing and tennis, I’m not very good at it. I gaze with envy at those lucky devils who nap on public transport and fight malicious urges to disturb their peaceful repose. If I’m not supine, in a quiet, warm room, with loose-fitting clothing, a firm mattress and a pillow shaped just-so, I can forget any chance of sleep. Let’s just say I can relate to the Princess and the Pea story. I bet she wouldn’t have coped well with being phoned in the middle of the night either.
If these nocturnal calls were all bona fide emergencies, I wouldn’t mind so much. It’s the crap that really riles me. I’ve received middle-of-the-night phone calls from patients who are constipated, patients with impacted cerumen (“Me ear’s blocked, Doc. I can’t sleep”) and patients with insomnia who want to know if it’s safe to take a second sedative.
The call that took the on-call cake for me, though, was from a couple who woke me at 11.30 one night to settle an argument.
“My husband says that bacteria are more dangerous than viruses but I reckon viruses are worse. After all, AIDS is a virus. Can you settle it for us so we can get some sleep? It would really help us out.”
I kid you not.
Genevieve Yates is an Australian GP, medical educator, medico-legal presenter and writer. You can read more of her work at http://genevieveyates.com
By Genevieve Yates
One reason why I chose to do medicine was that I didn’t always trust doctors – another being access to an endless supply of jelly beans. My mistrust stemmed from my family’s unfortunate collection of medical misadventures: Grandpa’s misdiagnosed and ultimately fatal cryptococcal meningitis, my brother’s missed L4/L5 fracture, Dad’s iatrogenic brachial plexus injury and the stuffing-up of my radius and ulna fractures, to name a few.
I had this naïve idea that my becoming a doctor would allow me to be more in charge of the health of myself and my family. When I discovered that doctors were actively discouraged from treating themselves, their loved ones and their mothers-in-law, and that a medical degree did not come with a lifetime supply of free jelly beans, I felt cheated. I got over the jelly bean disappointment quickly – after all, the allure of artificially coloured and flavoured gelatinous sugar lumps was far less strong at age 25 than it was at age 5 – but the Medical Board’s position regarding self-treatment took a lot longer to swallow.
Over the years I’ve come to understand why guidelines exist regarding treating oneself and one’s family, as well as close colleagues, staff and friends. Lack of objectivity is not the only problem. Often these types of consults occur in informal settings and do not involve adequate history taking, examination or note-making. They can start innocently enough but have the potential to run into serious ethical and legal minefields. I’ve come to realise that, like having an affair with your boss or lending your unreliable friend thousands of dollars to buy a car, treating family, friends and staff is a pitfall best avoided.
Although we’ve all heard that “A physician who heals himself has an idiot for a doctor and a fool for a patient”, large numbers of us still self-treat. I recently conducted a self-care session with about thirty very experienced GP supervisors whose average age was around fifty. When asked for a show of hands as to how many had his/her own doctor, about half the group confidently raised their hands. I then asked these to lower their hands if their nominated doctor was a spouse, parent, practice partner or themselves. At least half the hands went down. When asked if they’d seek medical attention if they were significantly unwell, several of the remainder said, “I don’t get sick,” and one said, “Of course I’d see a doctor – I’d look in the mirror.”
Us girls are a bit more likely to seek medical assistance than the blokes (after all, it is pretty difficult to do your own PAP smear – believe me, I’ve tried), but neither gender group can be held up as a shining example of responsible, compliant patients. It seems very much a case of “Do as I say, not do as I do”. I wonder how much of this is due to the rigorous “breed ’em tough” campaigns we’ve been endured from the earliest days of our medical careers. I recall when one of my fellow interns asked to finish her DEM shift twenty minutes early so that she could go to the doctor. Her supervising senior registrar refused her request and told her, “Routine appointments need to be made outside shift hours. If you are sick enough to be off work, you should be here as a patient.” My friend explained that this was neither routine, nor a life-threatening emergency, but that she thought she had a urinary tract infection. She was instructed to cancel her appointment, dipstick her own urine, take some antibiotics out of the DEM supply cupboard and get back to work. “You’re a doctor now; get your priorities right and start acting like one” was the parting message.
Through my work in medical education, I’ve had the opportunity to talk to several groups of junior doctors about self-care issues and the reasons for imposing boundaries on whom they treat, hopefully encouraging to them to establish good habits while they are young and impressionable. I try to practise what I preach: I see my doctor semi-regularly and have a I’d-like-to-help-you-but-I’m-not-in-a-position-to-do-so mantra down pat. I’ve used this speech many times to my advantage, such as when I’ve been asked to look at great-aunt Betty’s ulcerated toe at the family Christmas get-together, and to write a medical certificate and antibiotic script for a whingey boyfriend with a man-cold.
The message is usually understood but the reasons behind it aren’t always so. My niece once announced knowledgably, “Doctors don’t treat family because it’s too hard to make them pay the proper fee.” This young lady wants to be a doctor when she grows up, but must have different reasons than I did at her age. She doesn’t even like jelly beans!
Genevieve Yates is an Australian GP, medical educator, medico-legal presenter and writer. You can read more of her work at http://genevieveyates.com/