Sunday, August 18, 2013

Abdominal pain = Surgeons

There is an interesting rule at our hospital that anybody with abdominal pain is seen be a surgeon before anybody else. The reason for this is that most causes of abdominal pain are dealt with by surgeons. This is thought to stop patients coming in under another team and then having a serious surgical diagnosis missed. It is also about sharing out the inpatient work load as the physicians are very busy and is unfair them looking after all the non operative chronic abdominal pain. It might also have something to do with grumpy surgeons refusing to see patient's that they deem "not surgical".

 This is very noble and a good idea in theory but the problem comes when the abdominal pain is due to something surgeons aren't good at managing. Once a patient has your name on them, it is very hard to get another person's name next to them, even if they'd be better off with them.

Also not every patient with abdominal pain necessarily has a surgical problem. Below is a list of diagnoses that I have actually seen in patients referred to myself as the surgical on call.

- Inferior MI - Epigastric pain and sweating
- Right lower lobe pneumonia - Right upper quadrant pain
- DKA - central abdominal pain and sweating
- Pre-eclampsia - Right upper quadrant pain 3 days post partum. This was made even worse by her having a BP of 160/100 and no platelets which no-body put 2 + 2 together.
- Septic Hip - Right iliac fossa pain (and a limp!!!)
- Ectopic - Right iliac fossa pain + vaginal bleeding + pregnancy test
- Labour - Yes, I've actually had a patient referred to me with "Abdominal mass, amenorrheoa and intermittent abdominal pain. ?tumour". 4 hours later they gave birth.

I haven't managed to get the Porphyria patient yet. But all the others are true.

Furthermore, the converse is true. Many patient's pigeonholed into being "medical" later turn out to have a surgical problem. The below patients are all patient's I have been referred by the medical on call and needed surgery.

AAA - collapse ?cause
Pancreatitis - confusion ?cause
Boerhaave Syndrome - Chest pain ?ACS
Necrotising Fasciitis - Leg swelling
Small bowel obstruction - Vomiting

Here is an interesting idea. Why can't we diagnose our patients and send them to whoever the patient needs. Medicine is not all about fitting people along a pathway or fitting in a box. Not every abdominal pain needs a surgeon and many patients without abdominal pain do.

This isn't a moan about A&E doctors. I've done a couple of locums in there and I don't envy their job at all. It's the politics behind the making up of arbitrary rules of who sees whom that annoys me. Perhaps if we were all a little more trusting and a little more keen to take over cases that come our way, this set up wouldn't occur.

Saturday, August 17, 2013

Locum Agencies

I got very annoyed last week whilst on call. I think it was justified.

I got paged by an outside line during a particularly busy on call shift. This normally means a GP has a sick patient who needs to be seen or another hospital has a VERY sick patient with a vascular problem. Also, as the outside lines are on hold, the bleep tends to keep on going until you answer it. So I tend to answer these bleeps fairly promptly, sometimes even interrupting seeing patients to do so.

So I run to the nearest phone and dial the extension to be greeted by an enthusiastic male voice with the following:

Idiot: "Hello, Are you the surgical SHO on call? We here at Idiot Locums have multiple locum opportunities just for you!"

Dobber: "You know this is the on call page FOR EMERGENCIES?! Please do not call this number again"

I think I then got a bit uppity and self important with him, saying stuff about how I'm a very busy and important doctor and his call has potentially wasted time I could be spending with a patient. And then I was going to call switchboard to block calls from his number again. So all in all I spent another 5 minutes of my shift just trying to stop this idiot doing it again. I really annoyed me, because when I spoke to switchboard they said they put an emergency call through to us. So not only was he a time waster, he was a liar. I'm actually quite keen on locum work, if he had just asked our medical staffing department, he could have had my email address!

Pagers in general are a great annoyance. Not only is our hospital so lame that they can't pay for my bleep to get replaced as its 20 years old. It is also very obnoxious and inefficient. You can't receive messages so you don't know what you are ignoring whilst you are doing a procedure. They also give no guarantee that the other person will pick up the phone at the other end. Carrying mobiles is even more annoying as you can't ignore them and will keep ringing until you pick them up. I always feel sorry for patients if I have to interrupt their history for a bleep. Even an urgent one. Especially as to the patient, the story they are telling is the most important thing to them at that moment.

Another thing! When I say I'm "on call" people always assume that means I'm asleep all night and that I only get a couple of calls a night. This is wrong and on call does not mean that any more! On call means that I cover the entire surgical side of the hospital and I don't sleep (my contract even says it is not allowed) at night. I work very hard and then go to bed in the morning. So I should just say "working night shift". But that makes me sound like I pack shipping containers. Which with the size of some of my jobs wouldn't be far off.

Thursday, August 8, 2013

Why the blackout?

Once again there is an extended period of time between posts. That is because plenty has happened in the last 2 and a half months. Lot's and lots. So much that tonight is the first night free from all the things happening. I was so busy, I tried to make sure I had as relaxing weekends as possible. As it turns out I failed from my list of weekend activities:

20-21st Apr: Dinner with school friends, Coffee with work friends, Haircut
27-28th Apr: MRCS Revision
4-5th May: Working nights (8pm-10am)
11-12th May: Working days (8am-9pm), Travel to Sheffield for MRCS Part B
18-19th May: Lash with work friends, Harry Potter land for birthday
25-26th May: Football end of season party, Trip to London for University Football Reunion Game & Champions league final
1-2nd June: 2nd on call (8am-1pm), Hospital with Mrs
8-9th June: Finsbury Park for Stone Roses
15-16th June: Auntie & Uncle silver wedding anniversary party
21-23rd June: Brother in law's stag weekend in Wales.
28-30th June: Working Nights (8pm-10am)
6-7th July: Working days  (8am-9pm), Spa with wife for her birthday
13-14th July: Friday night out with cousin, Baby shower
20-21st July: University friend's stag weekend in Cornwall
27-28th: 2nd on call, wife booked in on Sunday night for induction of labour
3-4th Aug: Sister's wedding, Wife discharged from hospital
10th Aug - 2034?: Looking after child

So the last few months have included a new job in a new city, passed my MRCS, went on 2 stags, attended my sister's wedding and the birth of a new baby boy. All of which could be worth a post on their own. That's not to mention the football, the cricket, the NRL, the NHS "bailout" and a whole myriad of other events which have just passed me by in the last 3 months.

So, I'm still here, just a standard surgical trainee (for the moment) looking forward to that great challenge, which most people tend to undertake, called parenthood. I have been very worried about how I would fare as a new parent, whether I would notice if he was ill, whether he would grow up to be a good boy, whether I'm giving him the right amount of food. Then I look at some of the parents who manage to have children that live past age 5 and worry a little less.