Oxycodone

Working in a first available GP clinic gives me the wonderful opportunity to see how other doctors in my practice are managing these patients who come in to see the first available doctor. I must admit, sometimes I am scared.

Take the case of Mrs X, a woman in her mid thirties. She came on a Saturday at 7pm. Having had a read of her medical summary at the start of the consult, I note that she has had issues with back pain, having had a recent back injury, likely a simple musculoskeletal back strain. I quickly glance over at the previous treating GP’s notes, and see a few prescriptions of endone. I seriously hope she doesn’t ask me for more endone.

“What brings you in today Mrs X?”

“Well, there’s really only two things today doc. I’ve been having these flu like symptoms for the past 3 days. And the other thing was that I just wanted a pregnancy test. I’ve heard that there have been some recalls with some brands of home pregnancy kits with false negatives.”

After doing the usual history and examination, I give the patient a urine jar to collect a urine sample, and advised to come back into the room afterwards.

With the patient out of the room, I snoop back to the previous GP’s notes and the entries made.

2nd March 2017 – Presents for review of back pain. Wants Endone repeat.  


Scripts written: Endone 5mg, quantity 120. 5mg QID PO

 

15 March 2017 – Review of back pain. Needs more pain relief.


Scripts written: Endone 5 mg, quantity 120. 5mg QID PO

 

Having had a read of these notes, there are many things wrong. First are the extremely brief notes. Having read many of this doctors notes, his notes are at maximum 2 sentences. They hardly document anything at all, and I would believe theses notes will not hold up in a court should he need to give evidence.

Secondly, the fact that a whopping 120 tablets of endone needed to be given. Add to the shock, that 120 tablets should last 30 days, yet this patient has needed to get another script in just about 2 weeks.

Having been at this practice for just 6-7 weeks, I have only prescribed 10 tablets of 5mg endone to one patient who had excruciating hip pains from a work place injury. Even then, I had trialled him on just some panadeine (paracetamol + codeine) prior to stepping up to endone.

This makes me conclude that some GPs probably just end up giving anything the patient asks so that the consult won’t extend over 5 minutes (which in my opinion, is a very shocking way to practice medicine – at the end of the day, I will make my own decisions according to my own independent assessments, not on recommendation of the patient). I have had the temptation to do that at times just because it seems like the easy way out, but I always tell myself, the easy way out may sometimes be the wrong way out and end up later on, being the hard way out (eg when asked to justify decisions, or when in court for such decisions).

 

 

Advertisements

When patients think I’m too young

What often annoys me, is when patients think I’m too young, and therefore they perceive that I’m not experienced enough. It doesn’t help that I’ve only just started work as a GP, and every now and then I have to phone up my supervisor for advice. In fact, I probably still am quite inexperienced, but which starting GP registrar isn’t inexperienced? It comes with time, and right now, I’m doing the dam best that I can to improve my knowledge and experience, something which patients can’t appreciate in that 10-20 minute consult that I conduct. Never mind the weekends that I end up spending trying to study up on the cases that I didn’t know much about during the week.

I remember in the first few days of work at my practice, one of the patients said “oh, it seems that doctors are getting younger and younger”. In reality, I feel flattered that I look young for my age (I’m around 28 years old this year), but at the same time, I feel like that me being so young means that the patient won’t have as much confidence in my diagnoses, in my management plans.

Just yesterday, I had a 20 year old patient talk about “closing the gap” program, to which I advised that I wasn’t entirely familiar with it.

“Are you sure you’re a doctor?”. Fed up at this so called “joke” (what an utterly tasteless joke by the way), I shot back matter of fact “Yes, of course I’m a doctor”. From what I make of it, I don’t believe that she would have made such a “joke” if I perhaps looked much older. The fact that I was feeling a little stressed out at the time didn’t help, as the patient mentioned irregular vaginal bleeding. In my mind, I was trying to work out what the best approach was. Thoughts about ruling out pregnancy, ruling out STIs and ordering blood tests swirled through my head. But this patient’s a lesbian. Do I still do a pregnancy test? She seemed the patient that was easily offended, and very crass with her comments. I opted to do some blood tests, and stealthily added a “serum bhcg” to the form.

Being the youngest in the practice (every other doctor has greying hair), it would appear that if patients had a choice, they’d obviously go for the greying hair doctors. I mean, who would trust a young doctor who just started out over someone who’s had 20+ years experience as a doctor right? What they forget though, is that being young and still learning, I’m probably more up to date with the most recent guidelines, more technologically savy as well, and well um, less cynical as well.

But I don’t think all that matters in the 10-20 minute consult. It’s just first impressions. At the end of a consult, if I am able to convey a sense of confidence, an attitude and an approach that seems beyond my years, I hope that the patient won’t just think that I’m too young and inexperienced just based on how I look. That behind the young face is someone who has worked hard, studied hard, and knows what they’re doing to do a great job of treating the patient.

 

 

Now that I’m a GP, I get to see all sorts of people

As a GP registrar, I’ve come to see many different things. Some things are straightforward, some are a little more complex. The challenge is being able to manage both fairly well.

For those straightforward cases, they are time savers, and give me that little bit of confidence that I’m doing something right. But those more complicated ones, I end up spending time looking up databases and management guidelines to figure out what to do. And even then, I may still have to speak to my supervisor.

Working today, I got the opportunity to essentially to tell a drug seeker to get lost. Well, not so bluntly, but essentially, I told him “I’m not allowed to prescribe you that”. He ended up saying he’d go to ED (after possibly having a fractured hand because he punched someone yesterday – all in the name of ‘self defence’). Trying to tell this man up straight that I wouldn’t prescribe it was pretty tough I must say. The patient persisted and persisted, but I had to hold my ground and just say no.

My next patient was a woman who came in for review of her test results. Of course, being the curious one and trying to do a thorough job, I had to enquire why the tests were ordered in the first place. It was largely due to hair loss. A quick inquiry into her social background revealed more about her possible hair loss than any blood test could tell. She was having a strained relationship with her daughter, she was essentially cut off from family due to her current partner, and her father was quite ill. My hypothesis is that her hair loss could be from stress. The patient also revealed, that her partner just told her that he was leaving her right before dropping her off at the practice. She broke into tears right in front of me. I offered her some tissues, and tried to advise her about constructive ways of dealing with this difficult event ie don’t drink alcohol, get some exercise, get social etc.

We’re I’m currently working at, I see all sorts of interesting people. Probably because of the low socioeconomic status group that come through. Really, I see a lot of blue collared workers. I could have potentially seen more well off people by working across the road at the mall. But I don’t think I would learn as much, and wouldn’t be made ‘tough’ from the relatively well off people there.

Having come across a variety of people in the last few weeks, I realized that there’s going to be lots of stuff I don’t know. And also lots of people who may not be the most reasonable of people to talk to.

And this is perhaps where I think it’s important for me to stick to my principles. I believe in being respected as a doctor, rather than liked as a doctor. I think I’ll go further if I’m respected, rather than if I’m only liked.

The Last Day of Hospital

Today was officially the last day of hospital. I was doing the dreaded postnatal checks (which I have done usually on Saturday, and those were busy as ever), so imagine my surprise when I went in today to find only 9 postnatal discharges (I have usually had to do 14- 18, with many ward call jobs as well in between).

By 12 noon, I had managed to see all my patients. Best day ever I must say. It has never happened before, and I am so glad that it happened on my last day of hospital.

Even the PAOU (pregnancy assessment and observation unit) was “quiet”, so they didn’t really need the help I offered them. So, I ended up spending 5 hours doing something productive like reading up stuff on medicare (prior to my orientation tomorrow), and some stuff on hypertension.

Also, today was a really nice day. Last few days have been muggy days with 33 degree temperatures. Today was a nice 27 degrees. Very pleasant.

Looking back at my 3 years in hospital, I can say that I’ve come a fair way. But being in training as of tomorrow, I have even more to go. Hospital time was stressful at times, but I can certainly say that I have learned a lot from it, and I am grateful to my patients, to my colleagues and the to the registrars and consultants who gave me great support and educational opportunities.

Before I left the hospital, I posted some internal mail to “Human Resources” with my ID badge, parking card and a letter written on a progress note.

“Dear Human Resources,

Please find enclosed my ID badge and car parking card.

I have had a wonderful time working here at the hospital.

Kind regards

The Placebo Effect

 

I dropped it off at the internal mails box, to never see my name badge ever again.

Leaving the hospital, I crossed the street, before deciding that I needed to take a photo of the hospital entrance, and so went back. Just like my last regional hospital, I don’t know when I’ll be passing the entrance again.

I race off to catch my bus, thinking that this is the last bus ride back home from the hospital. A nice finish to the day, and a nice finish to the last day in hospital. I need to pack my stuff up for tomorrow for… The start of orientation as a general practice registrar

The Legal Responsibilities

The hospital system is the mash up of many different specialties, all with the common goal of patient centred care; people are sick, so they come to hospital to get better.

With these different specialties, comes different responsibilities, and if you overstep your boundaries and encroach onto a different specialty, there are legal liabilities. Hence, a physiotherapists providing medical advice about orthopaedic problems becomes a legal issue.

I understand why there are such legal liabilities, and in fact, I think these boundaries are necessary to protect patients. But having been in the hospital system, I think it can get pretty ridiculous at times. For instance, at the previous hospital I worked at, an ultrasonographer could mark out the level of pleural effusion, but would not mark the spot for fear of legal liabilities should any issues arise if it was drained. Hence the doctor (usually a resident) would need to come and mark the site that the ultrasonagrapher had indicated. So as a result, any issues with a drain insertion would be blamed on the resident, even though it was the ultrasonographer who technically marked out the site.

In a way, I feel that some of these legal responsibilities leads to a decay in upholding good moral standards. The other day I was asked by the nurse to come and console an anxious patient who had her belonging stolen by an outsider. It was a strange request, because what was I supposed to do as a doctor? I felt that a social worker would have been more appropriate. So I arrived and sat at the patient’s bedside, and started listening.

“Ms X, I’m sorry to hear about what happened to you. How are you feeling?”

“I feel terrible. This everything has gone missing including my phone and all my credit cards. I have at least 12 credit cards in my wallet!”

“Ok. Have you started trying to cancel your credit cards yet?”

“I have Westpac here in Australia, and all the others are in England. But I wouldn’t know how to cancel the cards.”

“Ok, maybe I can try and call the Westpac number and we can try and cancel the card.”

I went back to the doctors desk, and asked one of the nurses if social work was doing anything about cancelling the credit cards. Apparently, social work thought it was not their job to cancel credit cards, and declined to help (it was a Sunday anyway).

Anyway, the dect phone I was holding was too unreliable and kept cutting out, so I ended up asking the patient to come to the doctors desk to use the landline. Partway through, one of the surgical doctors asked me to come into a side office. When I got in, she stated firmly “You need to stop what you are doing. It’s not your role to cancel credit cards, and there are legal boundaries in helping her to do so.”

I had a think about this, and could definitely see where she was coming from. It looks sketchy to say the least when a doctor is helping a patient to cancel her credit cards. Almost like I could somehow financially benefit from the situation. I know I couldn’t do much for the patient aside from listening, so I thought the least I could do was to help her cancel her credit card to prevent someone from stealing her money.

In the end, her daughter arrived, and I quietly left the patient in the care of the daughter.

It frustrates me that because of legal issues, it prevents us from doing something decent. It’s something that I hear about to no end in China, where people are too afraid to help people on the streets who are hurt or ill, due to the fears of legal proceedings against them with false accusations.

But then again, in any system, if things like that are allowed to happen, then people end up changing. If the patient made a complaint against me, or if I was penalized for what I did for that elderly woman, I would be pretty stupid to do it all over again if something similar happens.

Anaesthetics

I’m still constantly amazed by the new stuff that I’m exposed to as a doctor. Take anaesthetics for example. This week is the fourth week I’ve been on it for, and yet I still really don’t know how to use that damn anaesthetics machine well yet. It’s got a lot of fancy knobs, 3 (yea, three!) monitors that displays lots of numbers and pretty graphs, and lots of buttons that I could press, but I’m afraid to.

My job as a resident anaethetist appears to be the most relaxing job I have done to date. I don’t have to hold a phone, and I don’t get pestered much by nurses (they’re all too fantastic at looking after recovering patients to give me a call 🙂 My job is to put oxygen on the patient. Well actually, it’s more involved than that, but putting on the oxygen seems to be what I do a lot of. As well as putting in cannulas, and taking a brief anaesthetic history of the patient.

I must admit, anaesthetics seems like an extremely cool specialty. For one, it is the only specialty so far that I have seen that gives allocated breaks (yea, another person actually comes to relieve the anaesthetist so that they can actually eat lunch). Next, it is the only specialty that surgeons can’t bully. If an anaesthetist says that a surgical procedure can’t occur, then it can’t occur, and the surgeons have to stand there looking dumbfounded that they’ve just been told that they can’t cut up their guinea pigs er.. I mean patients. In fact, one of the anaesthetists that I was with felt it was too unsafe to perform surgery on a patient, given the arrangement of the theatres – the theatre was too small, the equipment was way too far away from the patient, and the theatre was horrendously understaffed (the anaesthetist was not pleased that all the nurses had left at the same time, meaning the anaesthetist had to be the orderlie staff, the anaesthetist, and the nurse – yea, not fun to be 3 people at once.

I find it funny that I have learned more about operating theatre procedures, and have spent more time in theatres than I have in my 20 weeks of surgical rotations. I have actually felt like I’m learning new skills for once, rather than just using the pen. I have put in numerous laryngeal masks, and have successfully today intubated my first patient without any consultant intervention. It’s a great feeling.

But, I must say however, that I can’t imagine myself doing this long term. It’s as boring as hell. From what I’ve seen (largely elective cases, exclusions including emergency anaesthetics, paediatric and obstetric anaesthetics) the majority of cases go smoothly (95%), while only 5% provide you with some adrenaline pumping action. So it’s either goes very smoothly (boring) or extreme adrenaline action (stressful). I don’t think I’d really want a job that swings in between these two extremes. And perhaps I don’t feel like it’s very rewarding. Just sitting for hours monitoring a patient’s vitals, and occassionally giving some more drugs doesn’t seem to be a particularly rewarding job to me.

Did I learn much from anaesthetics? Yea, I learnt quite a bit, and got to do a lot of procedures. Was the rotation enjoyable? Not a great deal to be honest (I was told that I was supernumerary – yea, like a spare tire), given that I didn’t feel I was doing too much. Despite all this, I still respect the jobs that anaethetists do, although I feel like it isn’t something that would suit me.

Changes In Place

How time has flown. It has been a month since working at the big metropolitan city. Work seems to be hectic at times, sometimes even stressful. I have become more senior, but I some how still don’t feel ready. It’s that anxiety all over again. Am I good enough in the eyes of others around me?

What has been reassuring I suppose, was the revelation that I was still  expected to discuss every single paediatric case with either the registrar or consultant. This was revealed to me just a week ago when I had to meet my supervisor. What a relief in knowing that I wasn’t expected to be managing cases all on my own.

What still makes me extremely anxious, is in venepuncture. With 8 year olds+, I’m reasonably ok, but it’s the little babies that still worries me. If I miss, I’ll have to call a senior doctor given that it is incredibly distressing for the babies and the parents. I would like to, no in fact, I need the practice,  but every time the mother says something like “oh yea, he’s really difficult and it would be best if an experienced doctor could do it”, so I always end up asking the registrar.

I also find that 10 hour shifts seems a bit long, in that when I finish work, I find I have no time to relax. Well, it’s the pace that it works at, and I suppose I’ll have to adapt.

Another 2 and a bit hours and I’ll be heading to work. Not feeling entirely 100% since I have been recovering from a cold (I had to take yesterday off due to illness), but I still have to go.

I wonder what else I can do to break the routine of work and just home? Perhaps some volunteer work? Perhaps join some local clubs (where I can possibly meet the love of my life?) I think I need to find a girlfriend this year.

All In A Day’s Work

For the past week, it has been extremely busy. I attribute this to the deck phone I’m holding, the patient load my team has, and just being unlucky.

Firstly, the deck phone; it’s a blocky black and grey phone, which vibrates, and plays a ring tone that makes me shudder in fear every time it rings. It’s constantly like a lottery, except it’s a lottery of bad luck. If I’m “lucky”, I might just get a call about giving a phone order for Paracetamol. If I’m “unlucky”, I might get asked to see a patient who has chest pains, or someone who is short of breath (as I was told to just this morning).

My deck phone is extremely efficient; at creating more work that is. For some reason, I’m always the one holding it, even though there is a registrar and another intern on the team. If the registrar borrows the phone to call someone, it will somehow always make its way back to me. Same with when the intern “borrows” the phone. It will be handed straight back to me. Perhaps the most amusing incident was this morning, when the registrar said to me “since you’re on phone duties, would you like to make the phone call for transport services to get this patient transported to the metropolitan hospital?” Since I’m on phone duty…. I never wanted to be on phone duty actually, but I’m always being handed the phone by you guys anyway.

On my first day on the team, I told the intern, “I’ll take the phone today, but let’s take turns holding the phones on alternate days.” Seems that somehow this conversation was forgotten. I suppose partly it is my fault in not enforcing this upon the intern.

Today was particularly bad however. As I got on the lift to see a patient downstairs, my phone rings. I need to put a cannula in a patient. The patient needs protective equipment used (gloves and gowns). Starting the procedure, and all gowned up, the phone rings. I am not allowed to answer the phone because I’m gowned up, and because I’ve already started the procedure. The phone rings once for about 20 seconds, and then hangs up. This is followed by another two times. I think that it must be urgent given how many times I was called. Is a patient dying? Finishing the procedure, I call back, only to find that I needed to write up some eye drops for a patient. 3 phone calls missed consecutively, just to write up some eye drops? My goodness, I am scared to find out how many times the phone would ring if I was unable to answer it, and it truly was for a patient that was sick/dying.

Aside from the deck phone, the patient load seems to be quite a bit lately. We’ve been getting a few patients with some being a little bit sick.

There was one patient that I had to see yesterday who was tachypneic. A very anxious elderly lady who was essentially palliative, having a left mid ureteric stone, urosepsis and end stage COPD. She was deemed too great an anaesthetic risk to have her kidney stone operated on. So, having tachypnea of 32, and then later finding out her phosphate levels were critical, and then later finding out her troponin was elevated presented a major nightmare. In addition, the consultant wanted CTPA (her kidneys were too shot to be safe for the contrast) and the patient had refused a V/Q scan. So not really knowing, I ended up just putting the patient on therapeutic clexane. But wait, the patient had haematuria a few days prior….

When I saw the patient yesterday with her daughter, I explained to her about her deterioration, and why I was giving her IV phosphate. She asked me if I could euthanize her yesterday. She still asked me if I could euthanize her again today. I had to politely explain to her that in Australia, euthanasia was illegal, and I certainly was not going to euthanize her. I ended up phoning my consultant for further management, and spoke to the ICU reg in regards to placing the patient on CPAP. I suppose the patient appreciated that I was doing what I could to help settle her SOB and tachypnea, and when my consultant came around, she told him “this doctor is really good, he’s been running around everywhere to help me”. That was perhaps one of the more uplifting moments for today for what was a relatively crappy day.

It was about 3:45 pm, and my back was aching from the busy day. Just one more patient to see. But upon seeing the final patient, they seem to have had it for me. The patient had been on isolation precautions, given that she could have had respiratory viruses. Having been visited by masked nurses, and told to stay in bed likely, I can understand the patient’s frustruation. I was just unlucky enough to come in and get blasted to smithereens by this patient’s frustration.

When it comes finally time for home time, I decide to check my email and find out the new updated roster. The person doing the rosters had decided to put me working on Sunday now, without contacting me at all. It’s almost like I’m indispensable, and not doing anything on Sunday. I email her, and tell her that I already had plans on Sunday, and to schedule me in on such short notice, the very least she could have done was call me first. Yea, I doubt I’ll have this coming Sunday off. Best crappy end to the day of a very busy day.

Now, onto the dreaded tomorrow; the intern will be off tomorrow, so it will be just me and the registrar…. I really need that Sunday off….

Panic in the Restaurant

I’ve heard it said before, that chefs don’t like to come home to cook dinner. I see the truth in some of that, as the last thing that I’d really feel like doing on returning home from work, is to focus on more medical things.

But sometimes, there is no other choice, and you just have to. Medical problems that my parents or grandma wants advice about are directed towards me when I come home. When things like “I’ve been getting cramps these last 2 days, what is the reason?” are asked, it’s an incredibly difficult position to comment about. So I try and take a history to glean more information, essentially to determine if it is something serious in nature, or something relatively minor that doesn’t require urgent treatment.

When it comes to things such as these, I don’t want to end up completely treating my family members. I’m happy to provide some advice, but when it comes to some medical problems, I don’t have access to diagnostic tests to confirm suspicions, and that’s why I think that if the issue really warrants serious investigations and treatment, it is best managed by their regular GP. I realized that a doctor without any medical equipment, diagnostic tests or medications is the equivalent of a medical student – just full of knowledge and differential diagnoses, but essentially unable to do anything much else.

This concept of being unable to do anything much was best demonstrated just a couple of days ago. My grandma had only been discharged from hospital for less than a day, but she was extremely keen for some lunch at a restaurant. So out we went to eat some greasy unhealthy Hong Kong food (which gave my Dad and I diarrhoea later that night by the way). Part way through lunch, my grandma turned a sickening pale, then blue colour in the face. She became limp, head starting to slouch. Her consciousness seemed to slip away as seconds passed by. I thought she was having a stroke. Fear seized me momentarily, with pure negative thoughts of gradual decline to a terrible quality of life, and what may be a painful slow death after what followed.

“She’s not responding” my father fearfully exclaimed in cantonese. I must have snapped out of my fearful state following that, and pounced into “doctor mode” after out. Bolting to my grandma’s side, I immediately thought of ABCD, checking for responses (COWS – Can you hear me, Open your eyes, What’s your name, Squeeze my fingers). By now, I mentally thought of hitting the MET call button, which translated to calling the ambulance. Enlisting help from the restaurant staff, I calmly told them that my grandma was in trouble and I was calling the ambulance. The manager took over my phone, continuing the call as I couldn’t give the exact address.

Throughout all this, I didn’t feel like I did a good job. I didn’t know aside from thinking about differentials and continuously assessing her conscious state, what else I could have done in that situation. I felt completely powerless removed from the hospital environment. One of the nearby nurses from a GP practice was called over, and helped to take a BSL and blood pressure.

As my grandma become more alert gradually, her only concern was that I attend my job interview with one of the hospitals that I was applying for next year. She urged me numerous times to attend. After what seemed to be about 5 minutes, she was more alert in herself, and the paramedics had arrived. My mum would accompany her to the hospital, and from my grandma’s urging, I ended up attending the job interview.

Perhaps what added to a particularly anxiety provoking day, was when the interviewer gave me a clinical scenario about a MET call patient. What a coincidence – I’ve just been through one already.

Suffice to say, I probably wasn’t performing at my peak after what happened. The interviewer felt I was too nervous, and felt I couldn’t control my nerves (I found it odd for some reason for an interviewer to specifically mention that). I thought the better of mentioning what happened to my grandma – I don’t want to be seen as someone who wants sympathy points.

I went home by bus, and went straight to the hospital afterwards. My grandma had perked up much more, and looked much better. But what a day that was. What a day!