Confession Sofa Junior Doctor

There are over 300 different mental illnesses listed in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5).

 

This is basically a manual used by doctors to diagnose and recognize mental illnesses

 

Some of these are anxiety and mood disorders. These are two different types of disorders that occur in people of different ages. The majority of these disorders can be treated and are not fatal, but they could be a source of discomfort for the patient and family members if they are left untreated.

 

Bipolar disorder, also known as manic depressive disorder, is an emotional illness that occurs when a person's mood shifts from extreme happiness to extreme sadness. Someone with this type of disorder may seem to have it all figured out at times, but is constantly frustrated by their own inability to control their emotional responses. People with this disorder may go through periods of extreme highs and lows in mood and behavior, and sometimes go back and forth between the extremes of emotion. A bipolar disorder sufferer is likely to experience unusual, sudden changes in their level of emotion.

 

In addition to bipolar disorder, another type of this disorder is called cyclothymia. A patient with this disorder can experience short periods of extreme mood swings without experiencing depression. However, they also experience periods where they have normal levels of emotion and do not experience any changes in mood. This disorder is very similar to depression, but is characterized by episodes of high and low moods that do not last for longer than several months.

 

When a bipolar disorder sufferer becomes manic depressive, they may be depressed for longer periods of time. Their life may be stressful and difficult. For someone who suffers from this disorder, life becomes more difficult and often includes a feeling of hopelessness and helplessness.

 

There are other symptoms of this illness, which include hallucinations, paranoia, and self-harm, as well. When the patient sees things that are not there or is hearing things that aren't there, these symptoms can be mistaken for serious mental illnesses. They may be hospitalized and treated with psychostimulants. However, medication may only mask the underlying cause of the problem.

 

Another form of treatment for bipolar and cyclothymic disorders is Cognitive Behavioral Therapy, or CBT. It involves the use of several tools that teach patients how to change thinking patterns, change bad habits, learn to control and monitor their emotions, and behavior, and learn how to think rationally. about their problems instead of emotionally.

 

There are several forms of Cognitive Behavior Therapy that can be effective in treating this illness and preventing further mental illnesses from occurring. Cognitive Behavioral Therapy, as well as psychotherapy, can help patients overcome their mental illness and get on with their lives.

 

The types of Cognitive Behavioral Therapy that are most commonly used are cognitive behavioral therapy (CBT), and relaxation therapy. These therapies can teach patients to recognize, avoid, and control negative thinking and behaviors, and improve their ability to manage their feelings.

 

Psychotherapy, on the other hand, uses conversation to help patients recognize, identify, and respond to the causes of the disorder, and how to change their thoughts, emotions, and behavior. Psychotherapy also helps patients learn to identify and understand the relationship between their thoughts, feelings and behavior.

As you can see, CBT is a good treatment option for bipolar and cyclothymic disorders spermatogenesis.net.

 

While it is effective in some patients, it may not be necessary in all cases

 

When medications don't work, CBT and psychotherapy can help. In these cases, behavioral therapy may be used or medications may be prescribed. However, if you have bipolar and cyclothymic disorder and if these disorders are difficult to treat, cognitive behavioral therapy is often recommended. However, you can find alternative treatments for these conditions using natural therapies, alternative medications, or a combination of treatments.

 

IED stands for improvised explosive devices. A homemade explosive device is an explosive device that is built and deployed in unconventional ways. It can be constructed from more traditional explosives, like an artillery shell or a tank shell. IEDs are often used as roadside bombs. This type of improvised explosive devices are sometimes used by terrorists.

 

The first known IED to be used in a war was the Stinger missile. The Stinger missile had a very long flight time and was extremely maneuverable. It could be launched over long distances and traveled a very long distance before crashing land. Later on, a number of IEDs were built into cars with explosives hidden in their seats. In some cases, IEDs were also concealed inside vehicles.

 

IEDs have also been used by insurgents in Iraq. It is quite possible that insurgents will make IEDs for the purpose of attacking an enemy. There are a variety of ways that an IED can be made, including using everyday objects. They can be made to look like a regular weapon that an enemy would use, but it will actually have some explosives hidden in it.

 

A lot of people underestimate the potential for an IED. The fact that an IED can be made using everyday objects has led to it being used by criminals all over the world. The main reason that IEDs have become so common is because they are very easy to build.

 

In order to make an IED, you do not need to be a rocket scientist. The IED can be made from a variety of items. Sometimes, a simple IED kit will do. Other times, you can buy some items that you can buy over the Internet. Either way, you will need to get all of the materials in one place.

 

Once you have all the material together, you can start assembling your IED

 

There are several components that you should get. These are often things like nails, nuts and bolts, nails, and screws, which you will need to put together your IED. There are also a variety of wrenches and nuts that you will need to put together your IED as well.

 

Basic tools, which you should have on hand include: hammers, nails, and hammers. You will also need something that is specifically designed to pry open cans, and bottles, which can be found at your local hardware store. You will also need a hammer and a pair of pliers.

 

After you have made sure that everything is set up, you can now load up the equipment into your car and take it to your target location. You will want to be sure that you are covered when you get there. If you are going to be driving around in your vehicle, you will want to make sure that you have your cell phone with you to call for help or another car.

 

Once you arrive, you will want to make sure that you are covered. You will want to have a fire extinguisher nearby as well, especially if it is a populated area. You may also want to have a fire hydrant nearby in case of an emergency. You may even want to consider having a smoke alarm on hand, as it is important to have in case of an IED.

 

Once you have been notified of your surroundings, you will want to make sure that you have all of the necessary equipment on hand. If there is smoke, it is important that you find water immediately. It may be wise to have a fire extinguisher, flashlight, and some other firefighting tools nearby as well.

 

Once you are sure that you have the necessary equipment, it is time to make sure that you know what to do

 

Some people will try to run away while others will try to use a stun gun to stop them, but they may not be able to get away. Once you are sure that you know what you have on your hands, you will want to call for help and begin making your way out of the scene.

 

You may also want to make sure that you call for help, but in the mean time, you want to make sure that you are safe. By following these steps, you will be able to escape any harm from an IED.

Last week saw the “worst week in A&E” since monitoring began in 2010.

Much has been made in the media about the number of people breaching the four-hour target. There is also a shocking lack of understanding of what the four-hour target actually means.

The target is not for patients to be seen by a doctor in four hours. The target involves patients being booked in at the front desk, assessed by nurses, triaged by frontline Consultants, having blood tests and other investigations performed, being fully clerked and examined by another doctor, having a diagnosis made, being referred to a specialty team, and then leaving the department to go to a bed on the ward, or being discharged home.

I don’t have to point out that the potential for delay here is almost unquantifiable.

During my shifts in ED I would frequently pick up patients who had twenty minutes to go. I would sometimes pick up patients who had already breached. Usually, these patients had been streamed to the urgent care centre, and then referred on to ED. Because it is technically the same department, they come through on the same clock… So, from the point of view of the four-hour target, we have failed before we have even started.

The target has good and bad points. It is an arbitrary, statistically useful but morally obsolete tool, to aid us in defining our parameters and assessing our performance. It is as useful or useless as any predetermined timeframe, and the number itself is not the issue. The problem occurs due to the fixation on the target above other priorities. Used properly, the target helps us identify areas of weakness, and departments that are struggling to see their patients safely. In an ideal world, departments with more breaches should get more funding, for higher staffing levels, for increased number of observation beds, for larger majors areas. In reality, breaching leads to stressful conditions, forced decision-making, and compromised patient safety.

There are a few funny internet memes floating around about the ED. One of them states “save three people’s lives and no one bats an eyelid; breach one patient and all hell breaks loose.” I have been blessed with working in an ED where there are excellent working relationships amongst the staff, and patient safety is consistently a priority. Even so, I have often felt pressured to make a quicker decision about a patient, to take down the half bag of saline still running, to amend the timing of my medical entries in order to have one less breach.

Quite often, the balance of admission or discharge in ED hinges on a period of observation. It is impossible to accurately assess a patient’s condition in 20 minutes. The luxury of allowing them to sit in the department, with regular observations, and pain relief/a bag of fluids is often all that is needed to avoid an acute admission. Where I am working currently, they have recently reduced the number of ED observation beds from 20 to 4. This is in order to build a much-needed Acute Medical Unit, which in turn helps free up the ED by providing an exit strategy for medically accepted patients. However, this has significantly reduced the number of people we can observe prior to admission. These people are now sat on the AMU, occupying the beds that they would have occupied on an observation ward, only now they are being clerked by an additional team; there is a whole host of admission paperwork; and they will inevitably stay overnight, costing the NHS an additional £600 per patient.

The media is making much of the fact that higher ED attendances are leading to overcrowding and pressures on departments. This is only partially true. Yes, there has been a steady, expected increase in attendance leading up to winter. However, the total number of ED attendances in the “worst week”, were actually lower, nationally, than a comparative week in July of this year. So why the inability to cope?

Frequently, the reason for the backlog is the occupation of ED beds and trolleys by patients who have already been referred to specialties, but are either too unstable to transfer, or there are no beds on the ward. Obviously, if someone needs monitoring, and the only monitored bed is in Resus, then we are not going to chuck them out just because they are at 4:01. This has its own issues – what do you do with these patients when you have another blue light come in?

There have been so many headlines over the past few weeks:

A&E forced to turn away patients; Patients waiting 24 hours to be seen in A&E(!); A&E closures: the meltdown…

It doesn’t take much assessment to realise that when you close down an ED, the patients that would usually attend there will need to be seen somewhere else. And yet, it seems to have come as a massive surprise to everybody that in the wake of the closure of Hammersmith ED, the surrounding hospitals have seen increased waiting times, and Northwick Park Hospital has almost consistently been on divert, causing ambulance crews to telephone ahead and take patients to other EDs in the area.

I am a huge proponent of closing dysfunctional departments. Having worked in a failing DGH last year, I strongly feel that no ED is better than a failing ED. However, there seems to have been no foresight with the closures, and the government very much seems to be expecting existing departments to pick up the slack with no extra room, resources, or staff. Yes, there are planned improvements to the services under strain, but it all feel a little perfunctory, and will likely be too little too late. Northwick Park’s escalation measures involve turning corridors into patient beds; this is not a sustainable situation.

The College of Emergency Medicine has produced several recommendations for fixing our ailing EDs. One of these is the STEP programme, which is basically common sense. It states that there needs to be higher staffing levels, more inpatient beds to free up ED assessment trolleys, and better access to, and knowledge of, primary care services. All of this feels a little obvious, and one wonders why there is less about how we can implement this in the media. But, I suppose, it makes a less catchy headline than “A&E 4 hour wait crisis”.

Today, on the 70th Birthday of the NHS, I called in sick to work. Due to sheer exhaustion, and a complete loss of all the fucks I have left to give. I am a danger to patients. I have complete empathy fatigue. I have worked 80 hours in the last week, and I am broken.

I am annoyed by everything. How dare people be ill? I have lost my ability to make decisions. Juniors are asking me for advice, and I am struggling to comprehend the simplest of ideas. I can’t even decide what to eat for lunch.

I woke up this morning, and the thought of going to work actually made me cry. I have never had that before. Sure, I have had days when I would rather stay in bed, but I have never experienced such a negative, visceral reaction to the thought of doing my job. A job which I chose, and I used to enjoy.

I am simply exhausted. Doctors rarely call in sick, and when we do, there is an unwritten rule that you don’t call in on a night shift or a weekend, as they are traditionally understaffed and you leave your colleagues unacceptably short. For the last few weeks, every shift has felt like a night shift. We are chronically understaffed, and it is only getting worse. The retention of staff is at an all time low, locum shifts aren’t being filled in the rota due to the London wide pay-capping, and those of us left on a permanent rota are filling in the gaps.

We have over 3 hour waits as the norm now. Patients are defensive and angry as a starting point. They immediately rant at you for how long they have been kept waiting. If, as is often the case, they do not need to be seen in ED acutely, they are furious that you have kept them waiting so long to tell them to go somewhere else. The idea that A&E is not the correct service for your problem seems to be equated with us not caring that you are ill. That is simply not the case. No one is more frustrated than doctors when they see a patient, know exactly what they need but are unable to organise it. Referring back to GP is not laziness; it is an unavoidable necessity. Blame the lack of funding, not the clinician seeing you.

In the last 2 weeks alone, I have been called names ranging from “unfuckable dyke” to “racist cunt”. I accept anger and abuse as the norm. In A&E, we see people at their worst, and so to deal with that we have to be at our best. It is hard to be at your best when you are working 80-hour weeks with minimal staffing. It is hard to be at your best when you can’t complete the simplest of tasks without being interrupted consistently by people asking how much longer the wait is. It is hard to be at your best when patients would rather believe an internet diagnosis over the one you give them. It is hard to be at your best when you are operating on 6 hours sleep and you see more of your work colleagues than you do your family.

So as I sit at home today, on the NHS’s 70th birthday, about to leave the UK to go and work in another healthcare system, I am torn. I am incredibly proud to come from a country that is synonymous with free at point of access healthcare. I am overjoyed that so many people still think the system is worth fighting for. But I am also approaching my limit of physically being able to work within it. Goodwill and pride only take you so far, and as a bare minimum, I would like to ask everyone who has been marching in favour of the NHS this week, to try and be a little more understanding to your healthcare professionals when you see them in A&E. We are doing our best, and some of us are broken from trying to keep this system afloat.

Through our years of medical training we have assessments that are designed to give us feedback, both on our clinical skills and on our personal traits and interactions within the department. It is a testament to how poorly they are generally completed that I am in my 5th year of training, and in the last 2 weeks have received my first ever genuinely constructive, slightly negative, feedback.

And it wasn’t enjoyable.

There is a tendency in medicine towards feeling that negative feedback is a reflection on your character. Nobody likes to receive criticism, however constructive, but as a medic you spend the vast majority of your life attempting to be a good doctor, to manage patients in an appropriate and empathetic fashion, and you are continually striving to be the clinician you want to be. We go weeks and months, if not years, without useful direction or advice about our clinical skills, and speaking for myself, are fooled into thinking that no news is good news. Then along comes an appropriate feedback session, and you learn that you are not as good as you think you are. For someone with chronic imposter syndrome this means you feel like the shittest doctor in the world.

My current stage of training is a funny one, I am at the end of my SHO years and from August, if I stayed in the UK, I would be embarking on registrar training. I feel competent as an SHO and totally out of my depth as a registrar. In the words of Britney – “I’m not a girl, not yet a woman.”

My current department gives ST3s (my year of training) the opportunity to step up as registrars. However, they quite unhelpfully don’t distinguish on the rota or in practice between an ST3 and an ST6 – a doctor with 3 more years of emergency medicine experience. As a result, in an already very stressful environment, you feel like you are consistently underperforming and being held to an unacceptable standard.

I personally do not feel that it is appropriate for me as a doctor with a total of 20 months of ED specific training to be leading a resuscitation room alone in a major teaching hospital. I don’t feel that I should be managing majors alone and making decisions about all the patients seen by the more junior doctors. I definitely shouldn’t be doing this without appropriate induction or training. This is where it feels different to other specialties. I have friends in medical and surgical specialties who become registrars at this level. However, they have had much greater exposure to their chosen profession (at least 2 solid years prior to becoming a registrar), plus, I hope they will forgive me for saying, their knowledge base and patient variety is not as vast. As emergency medics we have to know a bit about everything, and be confident risk stratifying everything from chest pain through to ectopics. This takes time, and patient numbers, to achieve with any degree of certainty or safety.

I have really struggled with this year, and that was unexpected. I came from a hospital that had a bad reputation and no senior support, into an emergency department with some of the best consultants in the country, with 24hour consultant cover, and I expected more.

My first 6 months was in paediatrics and I had the best time. The teaching was unparalleled. The department was super supportive, and I never felt outside of my comfort zone without knowing exactly who to call about it. Admittedly, I had no paediatric experience, so they weren’t trying to get me to act more senior than I felt.

Going from that state to leading a busy ED area is stressful for anyone. And then when you receive feedback that you are not doing that effectively, it makes you defensive, and you fail to see the usefulness or accuracy in the feedback you are given. No I am not performing at ST6 level, and nor should I, or anyone else, be expecting me to. However, there are things that I can strive towards improving, in order to perform better and eventually become a competent registrar.

There is a reticence to acknowledge when we are out of our depth. Not the crushingly scary, sick patient in the middle of the night, out of our depth – everyone recognises that, if they don’t they have no business being in medicine. I am talking about the consistent, low grade effects of repeatedly operating just that little bit out of your comfort zone, and feeling unable to voice it because everyone else seems to be coping fine. Not having anyone check on you and make sure you are ok. Being the only senior in a department for others to ask questions to because the consultant is in resus. Just being expected to cope.

It takes a lot to voice unease when everyone around you is giving the impression of you being able to cope. And you can cope. But really, coping isn’t what we should be aiming for. Confidence is the aim. And my experiences this year have totally stripped me of mine. I have been made to step up into a role that I was eager to take, without any significant training, without acknowledgement that this was new and difficult, without someone touching base to see how I was going. And I coped. And now I feel less confident in my medical abilities than I have in a long time.

I am grateful to be taking some time out in August. The thought of continuing to ST4 training is enough to make me hand in my training number. I am approaching this move to Melbourne as an opportunity to see more patients, hone my diagnostic skills, and come back a better, stronger doctor and person. Or alternatively I will run away to the sun forever and never come back…

Today we woke up to the news that the GMC has won its appeal to the High Court, and has struck off Dr Bawa-Garba.

Imagine, if you can, returning to your job after a prolonged leave of absence (maternity leave in this case), beginning your role afresh in a new environment with which you are not familiar, and being told that your colleague couldn’t be in today, and could you please do their work too? Additionally you find out that your boss is uncontactable, the other members of your team all started 2 weeks ago and are just finding their feet, and the IT systems are down. Someone else, in a different team, makes a mistake for which you are punished, and at the end of a gruelling workday you make an entirely avoidable mistake, which leads to catastrophic consequences. Are you no longer qualified to do your job? Do you lack the qualities and experience necessary to carry out your day to day duties? Or are these exceptional circumstances, and an entirely understandable lapse in judgement?

This is what happened to Dr Bawa-Garba. She made a mistake, on the back of incredibly hard working conditions over the course of a 13 hour shift, and a 6 year old boy died. Initial investigations into the case found that her mistake may not have influenced the end result of the resuscitation effort – the outcome may well have been the same. As so often happens in medicine, the SUI team found multiple contributory factors leading to this horrific outcome, and ruled that no specific person was at fault. However, Dr Bawa-Garba was convicted of manslaughter, suspended from the GMC register for a year, and has now been completely struck off.

We hold clinicians to a higher standard than most. It is understandable – our mistakes carry higher stakes. There are horrendous consequences to our failings. However, can we blame individual doctors for an outcome that has occurred in a working environment that no sane person would find acceptable?

We, as doctors, often work shifts where you go 13 hours without eating, drinking, weeing, or sitting down. I have often joked, whilst on call, that I am treating a patient for hypoglycaemia or acute kidney injury, but that my blood tests may well be worse than theirs. We prioritise the need of our patients consistently above our own basic, human needs. We work in conditions that you would be sued for trying to impose on any other profession. And the worst thing is, we impose those conditions on ourselves. We consistently state that our working arrangements are unsafe, no one in their right mind would think that staffing a 500 bed hospital overnight with a medical team of 3 people is a good idea. Wards of 30 beds go from a team of 3-5 doctors during the day, to sharing the 3 on call doctors with the other 470 patients in the hospital. Even on days when the rota is fully staffed and all the systems are working, it is a disaster waiting to happen. Medical ward cover consists of running from one fire to the next, never feeling like you are winning. How are you supposed to prioritise your need to eat when a succession of patients are, literally, trying to die on you?

But hungry, exhausted, overstretched doctors make mistakes. It should not be news that we aren’t at our best when our last meal was 12 hours ago. I remember clearly finishing one day on call on the maternity ward, and passing out on the walk to my car. On reflection, I hadn’t had a meal since dinner the previous night. I was concerned about my ability to drive, and called a cab home. 45 minutes previously I had been responsible for resuscitating a patient, solo.

During my time as an intensive care doctor, I frequently covered a ward of 14 critically unwell patients, with no Consultant cover on site. I started the job, on a night shift, with no induction to the computer-based notes system, no idea how to review medications or change doses. No understanding of how the filtration machines or ventilators worked. The fact that both I, and the patients, survived those on calls is testament to the incredible standard of nursing care. The nurses on that unit saved me more times than I can recall. But it should not be the responsibility of the nurse to educate the doctor. By that logic, there is no point in me being there. I reflect on that unit, and the fact that nobody died as a direct result of my lack of training or experience is frankly baffling.

The GMC has gone on nothing short of a witch-hunt. Bowing to tragically bereaved parents, making an example of someone who did nothing more wrong than any one of us has done on countless occasions, but got away with due to circumstance. The CEO of the GMC released a statement following the outcome: “We are totally committed to engendering a speak-up culture”.

How do you expect to foster a culture of speaking out, when you victimise people attempting to reflect on, and learn from, their mistakes? Doctors are human. We will all make errors in our careers. I have personally made management decisions that have contributed to a patient’s death. We are a cohort of professionals that go into medicine in order to improve people’s health and lives. Nobody can make us feel worse about our failings than we already do. Nobody can berate us more than we berate ourselves. We worry about doctors’ mental health. We worry about a culture where no one wants to accept responsibility or blame. And then we have a doctor, with an exemplary record, who reflected on a difficult case, gave evidence to an investigation panel, and then had her reflective evidence used to bring a court case against her.

We are all Dr Bawa-Garba. I don’t need to know the case specifics to know that similar situations are happening across the NHS on a startling scale. That the people responsible for safe staffing and rostering are not the people living with the effects of shortages on the frontline. That the people who have made a scapegoat out of this doctor get to go home at 5pm each day, and never have to hold a person’s life in their hands while trying to remember the last time they had something to eat.

I am British to a fault.

I have been ruminating on aspects of our character that we may be unaware of. My other half is an Aussie, and when we first got together we had numerous arguments based around the different connotations of the word “fine”. Myself, a Brit, would tell her that something was fine, and expect her to infer that it was anything but. She, in typical Aussie fashion, took everything at face value and then was unable to understand why I was miffed (another classic British understatement).

When she moved over here she commented on our typical British greetings “Hiya, you alright?” and how there was no acceptable response to that other than “Yeah fine thanks, you?” We are not asking after the other person’s well-being, and if someone were to deviate from the script it would be awkward to say the least.

These discrepancies can be amusing, but our idiosyncrasies sometimes inhibit our ability to let other people in. This can have devastating consequences, particularly in Medicine. In addition to the British avoidance of talking about feelings, people in Medicine are also reticent to admit what they perceive as weakness, and emotional responses and feelings often get bundled away and taken home, not aired and explored in a positive atmosphere. Mental Health is still not addressed as it should be, and we continue to perceive the demonstration of emotion as a sign of fragility.

When you work it every day, it is easy to forget how emotionally taxing our job is. We see people at their worst, both physically and emotionally, and the range of conditions we have to deal with on a daily basis can often be a complete mind-fuck. You go from treating 4-day-old babies with sepsis, to trauma calling a teenager who tried to commit suicide, to dealing with the aftermath of a neglect case. There is often no time to think about it, no time to dissect your feelings about a case, and definitely no time to deal with the emotions that either of those actions would inevitably stir. You have to develop a way of coping that allows you to move on to the next patient, the next parent, and the next disaster. It is a fine balance. We traditionally shut off the parts of ourselves that struggle to process the things that we see, and we notice ourselves become less affected by our daily exposures. But this is not healthy, and it only takes a small thing to tip the balance.

Between 10-20% of doctors become clinically depressed at some point in their careers, and there is a higher rate of suicide than in the general population; particularly in the acute specialties, where there is a “stiff upper lip” attitude and a tendency to push forward in the face of signs that we are perhaps not as okay as we seem.

This has repercussions not just for us as physicians, but also for the way that we treat our patients. Up to 50% of Emergency Medicine trainees resign prior to completion of their training. As a specialty we are seeing the highest rates of burnout in the history of the healthcare system. EDs are becoming like warzones, and our already fragile mental health is about to snap. The higher rates of burnout correlate with self-reported depression rates of up to 40%, with associated lack of empathy and altruism, and increased rates of errors. Over the last few months, I have actively felt myself becoming more cynical, and less motivated to help people. A parent books in with their sick child and I am annoyed that they are there. The very reason that I trained to do this job has become a source of irritation.

This façade spills over into our home lives too. I am so used to shutting off my feelings about things that happen at work, that I attempt to do the same with things that happen at home. Over recent months I have been endeavouring to insulate myself from my feelings about both issues at home and difficult cases at work. And my mind simply doesn’t have the capacity.

I have recently considered going to a counsellor to help me unpack all the emotions I carry around with me, both from my personal and professional life. It has taken an almost daily struggle to keep those emotions under the surface to illustrate to me how important it is to deal with your responses to situations instead of packing them away, and using the traditional dark humour to cover them up. I have been less than keen to address these issues, due to both an inbuilt, British avoidance of talking about “feelings”, coupled with a desire not to seem nauseatingly American by attending therapy; but also due to the inescapable concern that it makes me a weaker person. That other people are managing, and by my admission I am not. That this somehow makes me a lesser doctor, a lesser person.

Acknowledging emotions is not a sign of weakness. Unpacking your response to a patient, or a situation, or your relationship, is the healthy way to deal with it and move forward. We need to stop prioritising relentless, emotionless work ethic above the ability to be normal, functional, people. We need to allow ourselves to be human.

Some of this needs to stem from a revision of NHS culture, for the establishment to recognise that lack of debrief, lack of NHS counselling, lack of self-care for our emotional selves is damaging to our productivity as a workforce, but most of it can stem from us, as individuals. If we are affected by something, take the time to feel it. Discuss it, dissect it, and get different perspectives on situations. Maybe not at the time, but we should prioritise debrief, prioritise acknowledgement of an emotional response. Allow ourselves to care.

We need to recognise, as individuals, that we are not built to carry all our stresses around with us. That showing compassion towards our patients begins with showing compassion towards ourselves, that when you are saturated by stress and emotional baggage you lack the capacity to truly help the patients that put their trust in you. We need to understand that overexertion and dependence on 3 coffees to get through the day is something to be avoided, not romanticised. That working hard doesn’t have to mean running yourself into the ground, and that taking care of our mental health is paramount to being empathetic, successful physicians.

Things I have learned so far in kiddies ED:

Bubbles have magical qualities and fix tachycardias ALMOST every time.
There is no such thing as a “quick look” at a child in triage.
Play specialists = HEROES.
Early ametop application in triage is one of life’s greatest gifts.
ALWAYS take a second cap gas because the machine demands one as a sacrifice.
Sometimes kids just get rashes, and we don’t know why.
All children in London are constipated.
Parents never give paracetamol, for fear of us not believing that their child was in pain/hot. We berate them for it, and then don’t believe them that their child was hot at home if they aren’t hot here.
I can now identify which antibiotics someone has been given based on what colour it is, what it tastes like, and what bottle it comes in.
Suctioning bronchy babies and watching them instantly perk up before your eyes is one of life’s great pleasures.
Sometimes a sympathetic face and time to listen is all it takes. Parents’ scope to worry about their children knows no bounds, and reassurance costs nothing. Be patient.
A good number of midwives scales are broken.
If the umbilical cord looks infected, it usually isn’t. When it is, it is a BIG deal.
Getting a line into a 1 day old baby gives you the best high.
Paramedics and GP surgeries NEVER have paediatric sats probes and this frustration will be felt DAILY.
When you get cocky about your abilities you will inevitably do something insanely stupid like glue a child’s eye shut.
When you finally know the doses for paracetamol and ibuprofen without looking them up you feel like a GOD.
SOME babies ARE cute, and you have to remember to give them back to their parents when you are finished examining them.

With apologies to Taylor Swift, I present to you the following.

Blank Space-r

Nice to meet you, what brings you here?
I could ask you almost anything,
Rashes, fevers, diarrhoea?
Saw you here and I thought
‘Oh my god, hear that chest,
He should be the next assessed’
The triage nurse is looking stressed.

Bring you in, sit you there,
Talk to Mum about what’s going on.
Assess your throat, look in your ears
And I know you are quite wheezy.
So hey, let’s give some puffs,
I’m hoping ten will be enough,
Grab your spacer, come with me,
I can make your breathing better for a little while.

Cause you’re young and you’re breathless,
You come to A&E.
Run out of inhalers,
No time to see a GP.
Got a long list of visits,
They all say the same.
I’ll give you burst and steroids
You’ll be glad you came.

I have now been in Melbourne just over a month.

I have settled into work at one of the teaching hospitals. We have secured a cute little flat within walking distance from work and a nice little coffee shop down the road. We have even taken our first trip to explore outside of Melbourne – heading to McLaren Vale and buying an unacceptable volume of Shiraz.

A couple of my new colleagues have discovered this blog, and one sent a screenshot to me asking if I wrote it. Aside from being amused at my now international almost-recognition, it led to me re-reading my last post, and I can’t believe how defeated I sound. I already struggle to recognise the Sheri who wrote it, barely 2 months on. I feel a little as if I am emerging from a thick fog. Things in healthcare here really are as good as people made them sound.

Traditionally this blog has been used to voice my annoyance at the general state of the NHS. It is odd to begin writing a post filled with positives. There are, however, in addition to the much nicer working environment, negative aspects of living in the Antipodes. I will probably end up comparing and contrasting more than just medical-related things over the next few posts.

Here are the things that have struck me thus far.

The COFFEE. Dear Lord, the coffee. I knew it was better. I was excited about sampling it. What I wasn’t prepared for was how difficult it is to get a mediocre cup of coffee in this city. Every small coffee shop has more delicious brews than the next. Chains like McDonalds (Maccas to my new friends) serve better coffee than independent shops back home. The Aussies are so focussed on superior caffeine, that even on night shifts there is a coffee truck that does the rounds of the Melbourne hospitals from 10pm to 6am supplying excellent beverages to all the night workers. Never will I be reduced to instant coffee again. Pure genius.

 

The rota (roster, as I am intermittently learning to call it). The shift pattern is just as terrible as back home. If anything, it is worse. I arrived in the country and immediately worked 3 consecutive weekends and then went straight onto nights. However, several vital factors mean that this did not bother me as much as it should. Firstly, you are paid fortnightly (hooray). The pay you receive varies depending on how many out of hours shifts you have worked that week. As such, weeks where you have worked weekends/nights provide you with a noticeable increase in your take-home pay. I know it supposedly works this way in the UK too – your annual salary is calculated to include your out of hours work, but you never see it directly. Seeing those extra dollars in your bank account after a weekend shift makes it exponentially easier to cope with.

Additionally, the workload is so much less. There is constantly more than adequate staffing, with time to make a cup of tea and have a little chat with your colleagues even during the “busiest” of shifts. I no longer feel as if I am continually chasing my tail and getting nowhere. There is time to properly assess, investigate and treat patients, instead of feeling as if you are providing a triage service where people are either referred or discharged without so much as a diagnosis considered or a brain engaged. People are less overworked, and as such more amenable to being contacted about patients for advice, even if you are not referring. There is more of a culture of friendliness and openness.

We are all used to the post night shifts breakfast where you get boozed and form the best bonds with your colleagues, dissecting the previous shifts and getting increasingly tiddly on espresso martinis, but in my hospital here, the Consultants foot the bill for these social engagements. There is a cap of $100, but it definitely shows appreciation for the night work. They can do this comfortably, and claim it back on expenses. Which leads me nicely to the next point:

 

Salary packaging. For those working in healthcare, you can set up a system whereby you can pay for certain expenditures such as rent/entertainment from your gross salary, prior to taxation. There is a cap of around $9000 per year, which gives your take-home money a significant boost, and again adds to the feeling of appreciation of your hard work.

 

I have left a training programme in a major teaching hospital, where there was a commitment to providing me with teaching and training experience, and am now working as a trust doctor in a smaller unit. One would assume that the teaching and training opportunities would have decreased. This could not be farther from the truth.

Despite the fact that I do not have a college affiliation, I have access to 5 hours of protected, PAID FOR, teaching on a weekly basis. What is more, the sessions are actually useful. Additionally, the ED registrars are all rostered to spend time in theatres, ensuring we keep our intubation skills up to date. It makes sense that you would want to keep practicing a skill that you rely on in an emergency, and I can’t believe we don’t do that in the UK.

 

You are much more responsible for your patient here. While the patient is in ED, regardless of the team they are under, you continue to make all the management decisions for them, obviously with consultation as required. If someone needs intubating, you do it. You put the lines in, initiate the treatment, and then call ICU for admission. It is so much more hands on, and exactly what we all signed up for when we wanted to become emergency doctors. It feels so good.

In addition to the above point, you can also do so much more for your patients here. Due to a combination of everyone being much less overworked, and funding being distributed differently, I have had none of the old frustration of knowing someone needs an outpatient review/further investigations and being unable to arrange them. Need to see a cardiologist? No worries. Need outpatient investigations ordered? Easy. Need an MRI for your ligamentous knee injury? No dramas.

 

I haven’t quite worked out how I feel about the public/private healthcare system. Honestly I don’t quite understand it. Perhaps it will become clearer the longer I am here. The private system definitely takes the strain off of the public hospitals, and provides fast and easy access to investigations, and prompt treatment for those able to pursue it, however, there are also negatives. Unnecessary admissions and investigations being one. I have had several conversations along the vein of “well, they don’t really need admission but if they are private we can bring them in for a few days and investigate.” And I am uncertain how I feel about that. You are obliged to encourage people to use their private insurance instead of taking a place in a public hospital. I understand the logic of that, but I am not used to feeling like a healthcare saleswoman, and I feel that it damages my integrity a little, especially if I do not feel the admission would be any different for the patient, or that the tests are unnecessary. I have had so many ridiculous conversations with extremely twattish private Consultants who clearly don’t care either way about their patients as long as they are being paid. Watch this space for more thoughts as I come to understand the process better.

 

Brand names. Dear God, Australia, learn what paracetamol is. Every drug is exclusively referred to by the brand. Not just by the public, but in healthcare too. The electronic prescription system requires the brand name to prescribe. You type Panadol, Voltaren, Lyrica etc. It drives me nuts that nobody knows what drugs they are taking and it’s even worse that the brands are so prevalent within the ED. I needed some metaraminol the other day and got nowhere until finally someone told me they call it Aramine here. It is a daily struggle.

 

Inherent racism/homophobia/intolerance of difference. This is a BIG factor for me. Australia is a developed country, with tons of educated people, and a net immigration per inhabitant of 4.5% (for reference the UK and US are roughly 1.5-2%). One in five Aussies were born abroad. It is therefore completely baffling to me that there is this degree of intolerance. People who I socialise with, who I consider to be well educated, largely with left-leaning politics, and a similar worldview to my own, have no problem voicing incredibly racist and offensive terminology. I have heard the word ‘wog’ in casual conversation more here in the last month than ever before in my life. I am not sure that I will be able to make my peace with that. I am told it is much worse in other parts of Aus, and that Melbourne is relatively tame in this regard, and that makes me feel sick. I am sure that their most recent Prime Minister and his anti-immigration, anti-marriage equality, extreme religious views is not about to improve the situation any time soon.

 

On a lighter note, it is VITAL that I pick my AFL team. I didn’t care much about footie teams back home, and assumed the same would be true here. But AFL here is life. It permeates every conversation, people form impressions of you based on your affiliation. Pretty much every conversation includes references to the players/games. It probably doesn’t help that I have arrived around finals season, but I clearly need to pick a team.

 

That’s it for now. I will keep you posted on further impressions as we go, but now I need to go out for coffee. Peace out.