Examining the Deceased Person

Two weeks into my medicine rotation, and I’m really starting to enjoy it. It’s a refreshing change from the mundane stuff I was doing in orthopaedics anyway.

Finding out that I would start medicine as the night ward call RMO on the last week of orthopaedics made me a tad bit apprehensive though. My apprehension was unfounded however, as the nights had seemed to be going well. I’ve got a very friendly and reliable registrar, and the tasks I’m asked to deal with are manageable at my current level of knowledge.

Perhaps one of the amusing things I’ve done so far, had been examining a deceased person. Prior to this, in the one and a half years of working, I’ve only come across one deceased person as an intern. And that wasn’t the greatest experience. But that’s another story for another day.

Anyway, I got phoned by one of the nurses asking me to confirm the death of one of the patients.It was an expected death with the daughter present there. I made my way to the ward, and carefully read the patient’s history. I looked at my watch. 12:40 am. As I got to the patient’s room, it was illuminated by a very dim light, throwing sharp menancing shadows over the patient’s face. Her lips were sunken in, and she had an open mouth, with eyes closed. Protruding cheek bones, and a pale face alerted me to the fact this woman would have been very frail and in poor health prior to presentation.

I introduce myself to the daughter, and explain that I’m going to be examining her mother. I call out the patient’s name, and start giving some tactile stimulation over the sternum. No response. I feel her radial pulse. No pulse. I try the carotid pulses. No pulse. I listen over her chest for breath sounds and heart sounds. Neither of those are present after 30 seconds of auscultation. Finally, I open her eyes to find big dilated pupils that don’t react to a torch light. The eyes looked out, almost as if they were made of glass. I contemplated doing the “rag doll eyes” test, but given the way the patient’s head was angled, and how the daughter was there, I decided against it. I calmly turn around to the daughter and say “I’m sorry to inform you, but your mother has died.” I glance at my watch; 1.04 am. The daughter sobs quietly. I ask her if there is anything I can offer her for the time being, like a cup of water. She politely declines.

I walk out of the room to document my findings. I am surprised that I wasn’t freaked out this time by a deceased person. I know I shouldn’t be saying this, but it felt different in a way (in my mind, kind of cool), seeing and examining someone who’s life ceases to exist. I felt detached in a way examining the patient. I felt emotionless, felt like I was just going about doing my job. I think what helped was that I hadn’t been involved in this patient’s care. Perhaps that’s why I didn’t feel so emotional. But then, I’m not so sure how I am supposed to feel after something so sad like this. Was I supposed to feel this detached, or was I supposed to feel at least a little something about a person passing away?

I’m certain that there are many more deaths I’ll be asked to confirm. So far, I have confirmed 3 deaths, which for my stage of training is probably considered quite low (thanks to me being in a more regional hospital with less patients). I am lucky so far in that the deaths of all the patients I have had to confirm have been expected deaths. I fear the unexpected death, and having to explain and answer difficult questions they may have, as well as dealing with reactions of family members like anger and denial. I hope I’ll have the experience and skills to deal with that in the future.

Back to the Surgical Wards

I’m back on that horrible horrible surgical ward, the ward of bad memories from last year. The constant buzzing in the ward of bells and alarms is all too obvious. I see some familiar haunting faces. Faces that give me a nauseating feeling of disgust.

It’s a good thing that those haunting faces are on the other side of the surgical ward. I’m looking directly back at those past surgical consultants that gave me such a hard time last year, from the desk of the orthopaedics team.

For the mean time, I’ll be looking after bones, joints and wounds, as opposed to botched up colon resections, dehisced surgical wounds, and bladder to abdomen fistula-from-bad-surgery (all of which I really did encounter during my surgical time last year) thank you very much.

Our orthopaedics patients are few in number (sometimes only 5-6 on the ward), generally quite well post op (joint replacements – what can go wrong?), and have far fewer comorbidities. Our team is fairly large too (3 residents vs 4 for surgery, but much fewer patients, and way less clinics).

Some of my registrars still suck, with one even being a registrar from last year. He assigns some of the most time wasting tasks for me, at one time, phoning me up and slowly dictating all the patient details to me so that I could write up a theatre booking form. It was painstakingly slow, dictating the patient’s name, and at times, missing a few letters so that I’d ask him to repeat again. Makes me question the registrar’s judgement in that firstly, it would be much quicker for him to fill the damn form out himself, and secondly, he’s not only wasting his time, but also the resident’s time, therefore wasting two people’s time.

Some things in orthopaedics remain the same as surgery however. The mad frantic rush in the morning ward rounds as we jump from patient to patient, and the unclear plans for VTE prophylaxis, as each consultant likes different VTE prophylaxis use. On the other hand, a lot has changed too. There are way fewer MET calls on our side, or constant requests to review unwell patients, and way less phone calls from other staff hurrying us to get certain jobs done.

Yeap, I enjoy orthopaedics way more than surgery. I’m just thinking how much it sucks for the surgical residents now, but I can empathise with them at least. Been there, done that.

The AHPRA Registrations Are Pretty Brutal

I had once looked up on the AHPRA website (the Australian medical register of pracititioners), and looked up my name, displaying it proudly to my parents.

“Look, I’m a fully qualified doctor” I showed to my parents.

They displayed a look that only any parent would display at one of their child’s proud achievements. They were proud of me.

But aside from that, I had learnt earlier as a medical student, that you could look up the list of deregistered medical practitioners. This was on my anaesthetics term, speaking to the registrar.

“One thing I hold to high regards, is practicing ethical medicine” she had told me.

“If you go on the AHPRA website, there is a list of deregistered practitioners, and the website also outlines in great detail why that medical practitioner was deregistered”.

I was pretty shocked about that, as the registrar went on to tell me how she recognized a classmate’s name amongst those names of deregistered doctors, explaining how her classmate had got involved in intimacy with a vulnerable patient.

I never really thought much more about that AHPRA website, but come a few months back, it got me thinking again. I had been studying some ethics in preparation for a GP interview that is coming up. Taking a bit of time out from study, I decided to have a read about what the deregistrations were about. And let me tell you, the website borderlines on intrusion and voyeurism.

For one, not only is the practitioner’s name fully placed on the site, but the practitioner’s place of practice as well, and several paragraphs outlining exactly why that practitioner was deregistered/suspended. I must admit, it did make for some entertaining read, but I just felt that it was really creepy and intrusive, especially the amount of detail they outline in those reports. And the fact that anyone with internet access can see that information. It’s pretty much the “hall of shame” for the entire world to see. That makes me that little more careful about being ethical as a doctor.

http://www.ahpra.gov.au/Registration/Registers-of-Practitioners/Practitioners-who-have-agreed-not-to-practise.aspx

For those interested, it’s up there. On a note, when I visited the site a few months back, there were several more entries, and the amount of detail was so much more. Looks like they scaled the details down a little bit.

The Patient Did What???!!!!

Perhaps one of the most “ewww” inducing factor I had come across happened to one of my patients. And it’s not very frequent where I go “ewww” because of a patient’s actions, but this one patient really did it for me.

So, having arrived at the psychiatry ward right after morning meeting, I go about my business ready to start my task of mundane ward jobs. One of the nurses approaches me, and I know that she wants to talk about the patient she’s looking after.

“Oh yea, I was wondering if you’d be able to write up some laxatives for Mrs A. She states she’s been suffering from constipation the last 2 days. ”

I reply “oh yea, so has she still been unable to open her bowels this morning?”

“She went to the toilet this morning. But she states that she had a lot of difficulty, and used her fingers to manually evacuate.”

“Manually evacuate”

I couldn’t help but let a wide grin form on my face. The patient manually evacuated because of constipation. It just doesn’t seem right when a patient does it.  I mean, I’ve done several rectal examinations (with gloves of course), but a patient doing a manual evacuation was just somehow very gross.

I saw her later that day, and asked about her bowel habits.

“How have your bowels been lately?”

“Doctor, they havn’t been to great. I tried to go this morning, but I’ve been really constipated, so I had to use my fingers.”

I fought back laughter, and tried thinking of lots of sad things to prevent myself bursting out into inappropriate laughter.

“Well, I can put you on some coloxyl and senna and some movicol”.

Whenever I see this patient now, images of two fingers manually evacuating faeces always conjures up. I can’t help it. I don’t know why after having done probably 20+ rectal exams, it’s only been this one patient that brings up such a strong image of fingers up bottoms.

On Being Genuine

The other day, my consultant saw me as we were about to do ward rounds and said “Hey doctor, how would you like to do a mental state exam on our next patient while we give you feedback later on?”

That was not a question at all I must say, in firstly, saying something like “no thanks!” would reflect badly on me. So I ended up saying “yea sure!”, and then felt the fear build up inside of me.

So in to the interview room we went, where there were two consultants, my colleague, one medical student, one nurse, one student nurse, and finally the patient himself. The patient himself was a man I had done the admission work for, so I knew his history.He is a man in his 50’s, who was brought in by police from his flatmate in regards to suicidal intent, and alcohol intoxication.

What happened next, was that I proceeded to establish rapport with him, asking basic things like “how have you been feeling lately?”, through a nervous bodily sensation. As I asked a few more questions, I felt more comfortable, and followed up on important cues such as his recent nightmares.

On closing, the consultant told me I did pretty well. He followed up with a few questions, such as “what specifically in hospital has contributed to your mood improvement?”. I wish I had asked that.

What surprised me next, was the consultant’s feedback that I was genuine in my interview with the patient. My interview persona was a reflection of how I interacted with others normally, and in a way, I brought my personality with me as the doctor, to how I am as a colleague.

In a way, it’s something I never really considered, but it’s something I feel is actually quite important. Being genuine with patients is a way of building rapport, and of being sincere to the patient. It helps to establish trust, in that in a way, it lets the patient know a little about the doctor’s true self. And I guess that being doctors, we don’t share our personal life stories, so the patient has very little knowledge about us as a person, other than their first impressions and the personality/persona we display to them. In that sense, to put forth a fake persona to patients, is really in a way distancing ourselves from the patient, in that a mask is worn so that patient’s don’t get to know the person behind the mask.

In a way, I guess my consultant has seen the fair share of other doctors who wear a mask, and adopt a different persona to patients compared to how they are normally. In my view, it isn’t authentic, and it would be difficult to maintain. Perhaps some feel the need to hide their true character between a persona to patients because of the fear of revealing too much? Maybe some try and adopt a more confident persona, or try and tailor themselves as a person similar to the patient to try and build rapport?

Now that I’ve come to it, I think I’d prefer a doctor who showed their personality through in a consult over someone who tried to be someone they are not. Eventually, it’ll show through that they are trying to be someone else.

But it’s definitely something I didn’t consider until now. From now on, I’m going to continue being genuine in my patient interactions.

Ok, I’m Freaking Out

I’m sort of freaking out here from what I read last night.

Last night, I read through some medical news. An article about an anaesthetic registrar who was abusing some drugs, and subsequently was banned from working in anaesthetics for 2 years (banning start date from around late 2013)

What shocked me most was the name given. That name. I have seen that doctor around my hospital. Perhaps there could be another doctor with the same christian and family name right? So I checked the doctor’s registry database. Only 2 doctors with the exact same christian and family name, except one of them must be at least 60 years old (he got his MBBS in the late 70’s). The doctor of interest looks like they’re in their 40’s.

So, I am kinda freaking out, firstly because I know of this doctor. And secondly, the fact that they were banned from working in anaesthetics for 2 years, yet I had corresponded with them last year when they were the on call anaesthetist.

Hmm, I hate to be a whistle blower and all, especially if my hospital isn’t aware of this doctor’s history.

Should I report this, and how should I go about it? To the medical board, or to my hospital?

Confused 😦