My wonderful moustachioed man at Heathrow.

 

My moustachioed man at Heathrow.

 

When I was 16 years old my big brother went off on a gap year, backpacking around Australia. I was jealous and wanted to go too but there was a problem – I was only 16. Eventually my parents compromised, I could go, but to visit my Uncle and Aunt in Brisbane and be back soon to start A levels.

 

I waved goodbye at departures, got through security (explaining that the cricket bat in a box was a gift for my cousin and was not a dangerous weapon, pre-9/11) and off I went on my own. I found a seat and as I sat down, tears started to form. I was emotional. I was 16.

 

There was another passenger already seated on the benches in front of me. Until that moment he had been hidden behind a large broadsheet. He slowly lowered his Financial Times and peered out at me over his glasses. Revealed was a tall, skinny man, larger than life. He was dressed in tweed with a remarkable moustache, a big bushy beard large enough to hide Basil Brush and Roland Rat and to top it all, he was wearing a wonderfully bright red turban.

 

“What are you crying for young lady?” he asked me, not accusingly, not aggressively, not patronisingly, just quietly.

 

“I’m going to Australia.” I sobbed.

 

“Mmmm, well that just sounds like there’s a wonderful adventure to be had and no reason to cry. You’re going to love it” and with that he was hidden again behind his newspaper.

 

I couldn’t help but stop crying and start laughing about at how silly I was being.

 

I never saw him again, not in person anyway. I think of him all the time though, when things start to get a little hairy and I feel like a 16 year old heading off alone to the other side of the world.

 

What a chap.

 

It is easy to fixate on the shit comments people have said to us, the ones that really stick in us like knives and do us so much harm. For some reason, remembering the helpful stuff is harder. There are plenty of chances to see the positive and be helpful and kind to those around us. If you are in a position of authority and even if you can’t match the remarkable facial hair of my wonderful moustachioed man at Heathrow, please offer up a good comment, you never know who might remember it, with fondness, 22 years from now.

 

 

I wasn’t expecting that – more encounters with suicide.

deep1

I wasn’t expecting this.

I wrote about my next encounter with suicide because I needed to think through how I was feeling. It had come up with some colleagues recently and I boldly claimed that we needed to be able to talk about it more. I shouted nice and loud…. We NEED to able to talk more about suicide!

I never ever said though, that it was going to be easy.

It all started out as a simple personal reflection on being able to recognise and cope with personal biases, especially as a medic. Suddenly I found myself with a huge number of readers, many of whom shared my post so more readers came.

They didn’t come for any horrific photos, they didn’t come to hear about the gruesome or to be peeping-Toms to the misery of others. It seemed to strike a chord in another way.

The bit that seemed to hit home was when I described how I felt about my personal encounters with suicide and how I dealt with it all. Or didn’t deal with it, as it turns out. I had a lot of private messages, some saying thanks for sharing and one or two being very long and heartfelt. I haven’t yet replied  to them individually because well, I wanted to take time, to get it right. Silly me, that is the very problem!  If we wait to say what we should say, if we wait to get it right, then too much time will pass and we end up not saying anything at all. Then the next time we see those people, we feel it is too late and we still don’t say anything. That’s craziness.

I am glad people felt that they could write to me. I am glad that they shared the same feelings and I am glad that we started a conversation. It has been hard though. A couple of friends have written to me telling me their stories, things I never knew about them, or that they had gone through. I hope it helped. I feel closer to them. I think about them differently now. Strangers too felt compelled to share with me how they felt about it all. I feel differently about it all now.

This is why we need to talk about it more.

However hard it may be.

Thanks too to all those who messaged simply to ask if I was OK and to let me know that they were there even though it was never about me. That was wonderful and shows that yes, we are looking out for each other. The world of medicine/nursing/paramedicine needs more of that stuff.

I am off to make some individual replies.

Suz

What is mildly amusing is that since I wrote that post I did actually end up in a bed on my ward via ED … Didn’t jump out the window though, don’t worry!

Stuff that may help:

From EMS1:  How to save a medics life

NYTimes: Why do Doctors commit suicide?

From PHARM: Are you OK?

From Mind : Suicidal feelings

From Samaritans: Suicide

 

A rising tide floats all boats.

threex

 

I was having a discussion about disruptive technology in medical education (as you do) and in a reply one particular line stood out for me…

I think the world is now mature enough to be sceptical about what we see and hear on the internet.

Sure, that is true for those of us who happily embrace the internet and internet 2.0 but there are still many who are not happy that we are out there, sharing our thoughts and having free open discussions with a global audience. We can’t be trusted, you see, to think for ourselves.

I still feel like the world is split into us and them – those who want to share and collaborate openly and freely and those who see value only in what they have to pay for and what they are told to read. As a commercial photographer, I spoke at numerous business group meetings and events about the beauty of collaboration and sharing using social media – only to split rooms in two. It is the same in the world of medicine.

I’m baffled that we still need articles like that in the BMJ this week bemoaning the tweet-dodgers at conferences, complaining that their data will be stolen or misinterpreted if anyone tweets from such private gatherings. It goes on to the suggest guidelines for conference tweeting…yawn…still needed in 2016? Clearly so. I have a colleague studying for a Masters in Medical Education to whom I recently had to explain the term FOAMed. His response was an eye-roll and a “whatever”. I think he and others are massively underestimating the power that online sharing and teaching will have in the future (and even now). Imagine a world where we no longer have to make sacrificial offerings to the gods of publications, to the gatekeepers of the journals who decide whether or not our careers are worthy of their ink. Judging academics by where they are published is just a ludicrous idea isn’t it? Yet my portfolio and my job applications would have it otherwise.

Until we can break free from the current outdated system, there will always be us and them. For many, what is seen as cheap will be seen as worthless. Anything that is hidden behind paywalls must therefore be far better? I disagree. Data/information/anything that we create – it can all be copied and shared on a massive scale on the internet – but that doesn’t make it worthless.

What we need to move towards appreciating is that the value comes not from what can be easily copied but from what comes with it, those things that can’t be easily copied or stolen – what is instant or timely; what is personal; analysis based on the experience and the validity and the accessibility of the authors. I’m talking about our ideas, our conviction, our experience and excellence – essentially, ourselves and what we bring with our data.

“I don’t have enough followers to bother” is a false predicament – you only need one or two followers who share your interest, who see something in your work and who will engage – this is all you need to get your work and ideas out there because there will be people who care enough about your vision to join in and to share. Maybe if there is one person reading my blog today who feels strongly enough they will share and discuss – that may be all I need. There is a phrase I have stolen (from someone who shared it with me) and I believe it strongly: a rising tide floats all boats. Information should be free to be shared in order to raise the collective up together and further. If you are on your way up, take others with you.

Open access for freely available research, data and even opinion undermines the established order – but we don’t want to do it to piss people off (maybe) we do it because we don’t need the established order anymore. It wasn’t working for us. It only ever worked for itself.

For research and education in the world of medicine, it is such an exciting time and it is time to accept that there is another way.

 

Part 2: Creative Commons : the best medicine? (watch this space)

It is your reaction that is the problem.

reaction2

 

I’ve been feeling a little uneasy about Scott Weingart’s opening talk from SMACC. It was an extraordinary talk, recorded live on stage for the EMCRIT podcast and it took quite a few people by surprise. He talked about meditation and negative contemplation….all good things, if they work for you, but still I am uneasy and here is why…

 

A few years ago I started a year-long job that was a bit of a distance from home. Far enough that I wasn’t going to be driving home after 13 hours at work only to come back again the next day. So I rented a hospital flat and was away from home for that year. On the first day, during induction, I was asked how I was going to cope being away from Mr Edge and our girls.

 

At the time, my answer was very clear. They are safe, they are well looked after, they are happy.
I was pretty chilled about it all because, and I can recall it so clearly, it was a time of horrendous fighting in Gaza and I had been watching online the devastation happening in the Middle East. The hashtag that stuck out for me was a chilling call for the International Criminal Court to deal with Israel. Now this is not a political blog post and I have nothing to say about that. Whatever the circumstances, as a human being, it was harrowing. In particular I saw a series of traumatic photographs of a broken man, walking a broken street with a plastic bag. He was picking up the pieces of his child, who had been torn apart by a bomb. The final image was shocking, it was a close-up of the contents of that bag. I think about that image often.

.
Scott was getting at this… Imagining the worst case scenario will always set you free to make a leap, because it will make you realise the unlikeliness of that scenario coming true. It will give you the strength and courage to face the difficulties of your day. But do we really need to be so graphic? I think about that image a lot. Perhaps that is my own personal negative contemplation. My children are safe, they are well looked after, they are happy but it is a painful way to remind myself that this is so.

.

I play along with the rhetoric and philosophy of the Stoics. I keep Marcus Aurelius at arm’s reach in my school bag. In fact the Meditations of Marcus Aurelius was the book I took with me to Dublin (did I think I was going to get a chance to read it?). Like Seneca himself I could probably be considered slightly less than stoic at times…but that’s OK, I am after all a work in progress. For a start I do not join in deliberately with any Negative Contemplation. I don’t ever deliberately visualise my girls dead in my arms. I don’t feel the need to go that far. This is something that Scott brought up in his talk, he says he does this, deliberately, daily. Understandably he was met with stunned silence in the large auditorium. He went on to explain how this and meditation helps him get through the tough stuff and how you too could make a start yourself on the path to inner peace.

In this arena full of high achievers, we all want this to work for us too. Since SMACC I have heard a few people say that they are going to start meditating. They are rushing home to give it a go. But this is a bit of a word of warning…beware that it may not bring what you’re looking for and that’s OK.

I am not being a #meditationwanker and I am not having a go at Scott Weingart, VERY far from it. We are looking now to a future where our wellbeing is considered much more important and we can discuss mental health issues more openly. This can only be a good thing. In the past this would have been unconscionable. We need people like Scott, with the reach and influence he has, to say that it is OK to seek out help like this and to suggest tools that could help. I’m just saying, personally, I struggle with the meditation that he suggests and negative contemplation feels to me like the sort of self flagellation I accidentally achieve daily anyway. As long as I channel it to positive outcomes then that’s fine and it doesn’t necessarily have to be quite so traumatic.

 

So what CAN I do?

For me it is writing. I write a lot. Only a tiny portion ever reaches publication – the rest is all shit (you might argue the published bits are shit too). I am guilty more than anyone of trying something only a couple of times before moving on when I am not suddenly representing my country or winning awards but

My point?
Do what floats your boat.

I have friends and colleagues who meditate and boy do they do go on about it. I spent a lot of time punishing myself for not finding it helpful. I did this too when I couldn’t find what I was looking for in Tai Chi…I gave it a chance but after I while I went back to kickboxing because really I just needed to punch and kick people to help me feel peaceful.

It doesn’t matter if you can’t do what Scott Weingart says. Give it a try. If you try (and like anything, you need to give it time) and it doesn’t work for you, recognise that you didn’t fail and you don’t have commitment issues. It just wasn’t your thing. Stoics see it like this – it is not the problem that’s the problem, it is your reaction to the problem that is the problem. If this doesn’t work, don’t go beating yourself up…and it is not Scott Weingart’s fault either. So,

 

Meditate
Don’t meditate
Imagine the worst case scenario
or don’t.
Write
Watch Football
Read
Run
Study

It is in the deliberate and in the mindfulness that you find your thing.

Strike your own match against whatever is going to set you on fire.

Just make sure you strike it somewhere and remember it is unlikely to be your last match and that’s OK.

Facing personal biases and my next encounter with suicide.

topfloor

 

The Friday night school disco was always an awkward, fun, silly affair with smoke machines, rotating disco lights and the occasional shifty bottle of MD:20:20 smuggled past the headmaster. I had danced with Harry, the new boy. He was a bit different, I liked him. We had similar military family backgrounds and being fairly new to the school he was having trouble adjusting because of that. He was fun. We were 14. Nothing else mattered.

 

On Monday morning as we took our seats for the new week, with stories flying around about who got up to what, our head of year entered the classroom. He asked for our attention, he told us to sit and listen and things suddenly changed. Harry is dead, he said, there had been a terrible accident. He explained how he had been playing a trick on his little brother, pretending to hang himself with his belt, he had slipped and he couldn’t be saved. We were 14 years old.

 

It has been a while since I was 14 years old. The school has been pulled down, the tree we planted in Harry’s memory torn up to make way for new flats. A long time has past and yet I still can’t shake off this nagging feeling. I just can’t bring myself to believe that this is what really happened. You see, I think Harry killed himself and for whatever reason, we were not told the truth.

 

I have lost an alarming number of friends, acquaintances and colleagues to suicide in recent years. Shall we take a moment and get past the joke that maybe they just couldn’t stand to know me any more? Thanks…moving on…

There have been the two hangings, the two drug/whisky overdoses, the jumping in front of a train (two of those believe it or not!) and one that I think was suicide but I have never asked because, to be frank, I can’t bear to hear it confirmed. At work I have seen a few people who have taken there own lives. If you spend any time with the ambulance services it doesn’t take long before you see them. A hanging, a shot-gun to the head, an overdose.

The fact that every time it happens I really struggle to deal with it may be my biggest problem here. I haven’t ever been able to face it and so I haven’t been there for my friends. I haven’t been to funerals or memorials. I have avoided any discussions. I have been so angry about each occasion that I have refused to hear the details, I have never questioned what really happened. I don’t get upset, I don’t cry, I just get very very angry.

 

I mentioned this to a senior medical colleague recently and she seemed a bit shocked.  “You’re going to have to get your head around this” she said “to work in the emergency environment and not, you know, go nuts. Also, you can’t be seen to deal with this so badly”. She was pretty blunt. I hadn’t really thought about it like that. She might have a point. I really don’t know how my own thoughts or feelings of anger affect how I deal with family members, or how I am seen to react. I just hadn’t considered that before – how does my own almost irrational bias manifest? Do people see it in me or do I manage to hide it?  I don’t know the answer to that.

 

Doctors are more likely to kill themselves than people in other professions. We know this. It makes me angry. Female physicians are just as likely as male physicians to take thier own lives. It is only a matter of time before I have to confront this again. I hope I never have to but of course I will. I suppose we all have our own individual hang ups, our own personal biases that might make us react differently when they come through the hospital door. At least knowing what mine might be is a good start.

Right now I work on the top floor of the hospital. The emergency department is downstairs at ground level. I sometimes joke with colleagues that there’s no point in jumping out of the window here…I would only land in the ED and as we are the only ward to ever have a spare bed I would just end up back where I started. I don’t think they realise that the thought had on more than one occasion seriously crossed my mind. I have, on more than one occasion, driven home along the small winding country roads (that have a habit of claiming a lot of lives around here) at over 90mph, willing a truck or tractor to come the other way so I could just drive into it. I have been there. It was a bad time. Please don’t worry, I’m not there any more.

 

So why do I get so damn angry when others go and end their own lives? I don’t know, but I have a suspicion it may go back to Harry. It may go back to wanting to be told the truth. It may go back to knowing that, with recognition and support, any one of them might have been prevented.

At work one day I asked a friend what was wrong. I hadn’t seen him for a while. He looked tired and unhappy. He looked like crap. He shrugged and told me he had a cold and I accepted that. Why wouldn’t I? A few days later I learned he had taken his own life. I felt so so angry. I still do.

 

Tuesday: I appear to have hit a nerve or two with this post. I am replying to personal/direct messages but I am a bit poorly (D&V, will spare you more details).

Please do leave a comment below if you wish to.

 

Some more reading:

Hopkins Medicine: Why do young doctors commit suicide?

 

 

 

 

Speaking out: teams, juniors, leaders and what SmaccDUB taught me.

Shetland

Landing on the wrong runway has left with me a story to tell for life. It probably gets more animated each time I tell it over a drink or two…but for once, I’m not the guilty party…ish. I say “..ish” because I wasn’t flying the aeroplane, I was sitting there, holding on with white knuckles and a voice in my head saying “he’s the pilot, he knows what he’s doing”. I said nothing, so perhaps, I too am guilty as charged.

We had been out for a day trip. It had been a beautiful day making it slightly hazy which isn’t always the best for flying but for me it was a great view. We flew over our house and flew over my old school in the Worcestershire countryside. We waved at the tiny flecks of sheep in the fields and followed the main roads as they snaked along below us. I love flying and strangely, the bumpier the better. But all good things come to an end and we had to head home.

As we flew back to the airport I listened to control – he was telling us to land on runway 3-4. That’s definitely what I heard, he said it a few times. The problem was, as we came in to land, in an unsurprisingly windy and bumpy descent, I couldn’t see a 3 in front of me. There was, however, a giant, white number 2 painted on the runway. Something didn’t add up. This wasn’t the right runway but I wasn’t the pilot. I didn’t speak up. I just thought I must have it wrong. He knows what he’s doing after all.

It was a very bumpy ride but rather skilfully, he managed to land without incident. There were no other aircraft or obstacles to hit and we got away with it. That doesn’t mean the pilot wasn’t in trouble!

Last week I flew (as a passenger) back from SmaccDUB to Aberdeen. The lady in the seat next to me was not a happy flier. It was another bumpy one, the weather was rubbish (welcome to Scotland) – she hated it. She sat there hyperventilating and holding on to the armrest and then my arm. I was loving the turbulence but I didn’t think it was a good time to tell her my story. I did tell my colleagues who had been on the same flight as we stood waiting for our baggage – and their immediate (just back from SmaccDUB) critical care doctor’s style response – “Why the hell didn’t you speak up – have you learned nothing?”.

Well, that’s easy for them to say. I think flattening hierarchies is easier said than done. If you’re the boss, just allowing me to call you Rob at work isn’t suddenly going to make me question my judgement less or yours more. That’s a confidence issue that as a junior doctor, I’m not the only one who struggles with. There’s a lot of work to do to make the team understand your reasoning and play along.

The talks at SMACC were delivered by experienced and thoughtful bosses. There was a lot of discussion about leadership, team working and vulnerability in this line of work, about looking after each other and watching your choice of words. Will it help me develop leadership and understand team dynamics? Yes.
Will it shape the direction I go in? Probably.
Will I speak out when I need to? Well, I spent my week in Dublin surrounded by grown up doctors from my hospital. I probably didn’t contribute much because I didn’t feel I had much to contribute. I love this picture of us…and I am not stuck on the end but right in the middle. It will make life easier to have discussions when I am back at work, of course it will. They aren’t as scary as they look 😉

dubx

Would I speak up? Yes, now I would but it isn’t easy. Speaking up or calling someone out isn’t easy, whether or not they want you to “just call me James” when you’d rather say Mr Surgeon-Sir. Some of us just find it easier having rank slides. Dealing with team dynamics and leadership is not easy – wherever you fit along that flattened ladder. Some of us don’t find it easy to walk into a room of 2000 people and end up friends with everyone even if there is a free bar and Guinness is flowing. We are all different. I’m not necessarily quiet, I sometimes do say it how I see it. I sent a peace offering to someone the other day and have been met only by silence…you can’t have everything but you have to try.
These so called soft skills are anything but soft just as Liz Crowe (@lizcrowe2) told us in her fabulous talk about love in Dublin. For me, they are harder than learning renal physiology or anything anatomy related for exams. I don’t think I’m alone in that and that’s why we need conferences like SMACC. This week I have managed to keep up my life-long 100% pass rate for exams…but I think when it comes to the soft stuff, one way or another, I fail daily. SmaccDUB taught me that.

A Touch of Mountain Medicine

WMT’s Mountain Medicine Course

You have the chance to be an expedition medic. Which group would you choose to join?

  1. A charity walk with thirty people climbing Kilimanjaro?
  2. A school trip to India with thirty 14-18 year olds?
  3. A high altitude climb with a small group of fee paying climbers?

It’s not what you might expect to be debating, sitting on the side of a hill on a beautiful calm October day in the Lake District. The small group of doctors (and one nurse) joining the Mountain Medicine course run by Wilderness Medical Training had some interesting and entertaining views. They were views based on a range of experiences and it made for an excellent weekend.

The Wilderness Medical Training courses including the 2 day Mountain Medicine course are open to doctors, nurses and medical students interested in medical care far from home. This October the group was made up of one nurse and a range of doctors including a few FY2s, a couple of FY3s, GPs, anaesthetic trainees and Consultant physicians. They all gathered at the Grasmere Hostel for a weekend of Mountain Medicine. Some were there taking their first steps to find out a little more and others there to add to their already impressive experiences.

The Grasmere Hostel was an excellent, very clean and modern facility with kitchen, dining area, sitting room, sauna and conference room space (as well as a drying room which wasn’t needed). There was no real need to venture out to the local pub next door but we did of course. We had some pub grub with one or two beers whilst getting to know the others arriving for the course ahead.

The chat was about previous courses, about current jobs and about the hot topic of the junior contract, though all these things seem pretty distant when you’re sitting there watching the sun set over Cumbria.

The first day started with bacon and eggs and introduction talks from the instructors who were straight to it, imparting their knowledge and clear expertise. This wasn’t teaching from the books, this was teaching from experience, and it showed. Talks included how to prepare for an expedition and basic navigation.

The reality of being an expedition medic isn’t just about knowing your ABC from your um, elbow. Being part of the team leading an expedition means that the medic on board should know what’s going on around them. That’s true for the preparation, route finding, navigation, security on steep ground and all things expedition related as well as being the one dealing with emergencies. The course covered these and more. Day two covered topics such as high altitude and cold injuries.

Walking in the hills in smaller groups allowed time to discuss relevant topics between group activities. Discussion points included group dynamics, water purification, medical kits and communication technologies, until it was time to deal with an injured climber on the hill, secure someone on a steep patch or cross a river.

Back in the conference room after a warming dinner and with the wine flowing, the instructors each gave a personal, inspiring talk. In one evening we went from breathing bottled Oxygen on top of Everest to taking prophylactic Diamox at altitude in the Antarctic, to sipping cold champagne in the Frozen Arctic for a romantic honeymoon story. A final talk gave insight into how we could find our way in the world of Wilderness Medicine and it was all very positive. Two days just aren’t enough though and this introduction to Mountain Medicine really only gets to scratch the surface but it was enough of a scratch to get this medic hooked again.

And my answer to that earlier question about which trip I would choose? Can’t I do all three?

A doctor taking a rest inside the Gamow Bag

A doctor takes a break inside the Gamow Bag

Tips:

It helps if you have some knowledge of navigation to start with as time is short. Knowing your Ordnance Survey maps, the scales and the symbols on them will help. Also, you have to be fit enough to be able to walk in the hills for an afternoon or two but vast previous experience is not necessary on this course.

Pros:

Excellent preparation information and joining instructions. Use of social media to bring the group together to help with transport prior to joining. Very nice and clean hostel facility. The clear experience and professionalism of the WMT instructors. The Medic Course Notes book is an impressive manual of all things Wilderness Medicine. This take-away manual covers a lot more that the two day course can.

Cons:

Two days just isn’t enough time! Parts of the course felt a bit rushed towards the end in order to fit it all to the time allowed.

The costs:

At £420 for the weekend, it will bite into your training budget but it compares well to other two day post graduate courses. You get a lot for your money, including an impressive hostel and 12 CPD points if that’s what you’re after. You will have to pay for travel to Cumbria.

Other courses run by the group include Chamonix Mountain Medicine courses in Winter, on skis and in Summer as well as the annual Morocco Mountain Medicine Course.

WMT

WMT’s Commercial Director Barry Roberts walking down with the group after a beautiful October day in the hills.

 

 

 

Small town excellence

Sometimes you have to turn things on their head and look at them in another way. I was made to recently by the boss…who had a slightly different (and of course far more experienced) point of view.

crackinthewall

I was grumbling to some colleagues about a subject that seems to be becoming my thing…the fact that where you live really shouldn’t determine if you live.

But it does.

Time and again I read and hear examples of this being so.

Scotland’s aeromedical service (@EMRScotland) only this evening pointed out on Twitter that London Air Ambulance (@LDNairamb) has 2 dedicated trauma teams on tonight, and Scotland has none. Northern Ireland has none. Dr John Hinds (@DocJohnHinds) regularly points out such inequalities and that trauma care in Northern Ireland is something of a lottery.

Where we live has consequences when things go wrong.

When my husband and I bought our beautiful cottage amongst the mountains we could not have been happier. For our youngest daughter, things were not so great. The day we moved in she became unwell. The bad nausea, vomiting, fever, photophobia, stiff-as-a-board type of unwell. I phoned the out of hours GP service and they sent an emergency ambulance. As Mr Edge went out into the dark to guide them to the house, I contemplated the longest time it would take to get us to hospital. I couldn’t help but question our decision to move so far from the big city.

But we chose to be rural and I know what you’re thinking. Scotland isn’t quite the outback…we aren’t relying on @ketaminh to fly us miles and miles across the land to definitive care, but none the less, where we live could have a huge part to play in whether  or not we live, should disaster strike. Distance to a local hospital might not be that great, but next stage distance to a teaching centre with ICU, neurosurgery, interventional radiology and dermatology (OK maybe not dermatology so much) being available on site must have an impact on the local population? Doesn’t it? Are there any studies?

Sure, we should strive to be centres of excellence in big cities, but we should be striving for even more than that if we are far away.

We have a brilliant District General Hospital. It is staffed by many talented,  enthusiastic and slightly eccentric but reliable and committed generalists. We are sometimes viewed by the specialists in the big city as being another ward of the Trust in which we all belong. Most of the time though we feel like the crazy Aunty that nobody wants to sit next to at a family wedding because she smells of mothballs.

Things are different here.

REBOA carried out on a London street to save the life of a young trauma victim is science fiction to us. If you suffer a traumatic cardiac arrest on the roads around here, you’ve had it. Sorry, did I use the word if? This is happening on local roads every single day just now. But I’m not just talking about the sexy trauma stuff. I’m talking about the other every day life changers: the tumours, the brain haemorrhages, the clots, the STEMIs and the time it could take to get you through the DGH system and on to definitive treatment.
Having a STEMI? The cath lab is quite far away, will thrombolysis do?
Emergency neurosurgery? Good luck with that.
Abdominal pain at night? Hi, I’m a new FY2 (seriously, that could be me you’re getting first).  I’m not really sure if DGH populations understand that? I didn’t before I came here.

The boss stepped in at that point…she stopped me in my tracks. She put it like this…

Of course it’s obvious that where we choose to live determines our chances….but our chances of what exactly?
Because of the geographical gap between us, it can make life harder to get people to the end result they might need but we do get people out the door and down the road when we need to. 
I believe that it is because we DON’T have all of their snazzy potential interventions and “things to try” at ANY cost, that we are far better at discussing and considering all the options, including death. Good old-fashioned end-of-life, death. We do palliation really bloody well. Sometimes, that’s what people really need and packing them off the big city might not be for the best. Providing a good death, with family nearby and consideration of comfort, dignity and DNACPR are as important when needed as ICU when it’s appropriate. I think we do that really well here.

She’s got a point.

The local population might not appreciate how different their care can be far from big teaching hospitals but maybe like me, they choose to live (and die) here anyway and for other reasons.

As for my daughter, after what seemed like a vey long trip, she jumped out of the ambulance, shone the pen-torch in her own eye and giggled on the long journey home with the packet of biscuits the nurses had given her. We didn’t sell up and move back to the big city. Not yet.

****

I posted this blog post about 24 hours ago. Since then I have learned the sad news that Dr John Hinds died today in a crash doing what he loved…risking his life to save others. Northern Ireland deserves the same care services as the rest of the UK.

Where you live shouldn’t determine if you live…but it does. RIP Dr Hinds.

 

 

We’ve always done it this way

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There is not a phrase in existence that I could despise more.

Please don’t get me wrong, as a junior doctor it is a phrase that has helped me out of a few sticky situations when uttered by an experienced nurse who’s watching my back. I’m talking about the other context though, the one where we’re trying to improve, innovate or are daring to hope to make things better and when we are met by this giant, immovable, smug, grinning brick wall of “always”.

I can remember, in all detail, the very moment this intense hatred began. In the summer of 2001 I had just graduated with an Honours degree in Medical Molecular Biology and was waiting to start Med School. I got a job in the University bookshop. Perhaps I should have realised beforehand that my exuberance was not suited to such an endeavour but at least it taught me so, and quite quickly. I worked in the back office, selling books to libraries (not a tough job as it turned out, as books were all libraries seemed to buy).
The shop’s systems were laborious and complicated and there wasn’t a computer in sight. For the student who had started the first tentative websites for the University clubs and sports societies, this was hard going.

I arrived at work one day to find a new batch of deliveries. It was periodicals day. The publishers sent them out to us and it was my job to sort them out, figure out who they were destined for and make arrangements for delivery.

After an age of time-wasting I couldn’t take the system any longer. I made a suggestion to the boss— Margaret. I didn’t whine, I simply made what I thought was a useful suggestion. I gave a solution to this time-wasting problem and I set out an argument for implementing it. Margaret, who glared at me over the top of her glasses, was not impressed. She lifted the tatty old notebook marked “periodicals” from the shelf, opened it up and handed it to me across her desk.

“This is how we have always done it” she said

and that was the end of that.

As I turned to leave I looked down at the notebook, to the page that she had handed me. What I saw stopped me in my tracks. The very first entry in the book was dated 14th December 1978. The day that I was born. Even more striking was that it was written in Margaret’s own distinctive handwriting and she had written in it, the same way, every month since.

She was happy with that. Some people just are. This was a battle I wasn’t going to win. I didn’t stay long in the back office selling books to libraries.

That bookshop is no longer there. Those periodicals are online now.

So here’s how it makes me feel when you utter those words. You take all creativity, innovation, excitement and hope and you stamp on them, kick them, punch them in the face and bury them in a box. You draw a line in the sand and you take your place on the wrong side of it.  There are two types of people on that sandy beach of yours. Those that proclaim we’ve always done it this way and those who move with the dunes.

 

Advice to my junior Dr self – but will I listen?

 

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What advice would you give your younger self, just graduated from medical school and about to start as a Foundation Year One doctor?

I love reading the sometimes hilarious #tipsfornewdocs and they will probably start appearing again pretty soon but we usually see these articles and blogs pop up all the time – asking people what they would advise their younger selves about to start it all. I was reading a rather good one the other day and that’s when it struck me.

Not only do I have advice for my younger self starting FY1 – I am also in a position to listen. I have this chance to advise my FY1 self, 8 years on, because I am about to start it again.

Yeah sure, these things will not be based on the last 7 years as a clinician – but they are based on the few years of the life that has happened since…and maybe that’s a good thing?

So, at the risk of sounding a bit Baz Lurhmann…

Ten things I am trying to get through to my younger self:

1. Wear sunscreen – but accept that the guidance for you to do so WILL change.
When you do need to change, don’t be annoyed that you’ve been doing it for years, those days are gone, things change. Move on.
Did I mention Baz Luhrmann?

2. Nobody expects you to know everything. If by chance you do know the obscure answer to a seemingly random academic question on your next ward round then this will actually surprise everyone. Honestly, don’t worry – the students will be back soon so it will take the heat off.
Also, however much you read today – it will not come up on tomorrow’s ward round. But that’s not the point is it?

3. It is really hard to make a right turn in busy city traffic but it isn’t impossible. Be patient but be ready to pounce when the time is right. Should you make it, you will get home quicker but failing that, you can keep making left turns and you’ll probably still get home.

4. Advice is about them, not about you. Advice from anyone is about what THEY would do, based on THEIR experience. Say thanks, consider it, but you must add your own experiences to the pot too.   

5. THAT vending machine. You know the one, at the end of the corridor outside Ward 8 – right outside the ED back door. JUST STAY THE HELL AWAY FROM IT.

6. The opinions of only a very few people actually matter. I don’t think I can put this better than Brene Brown. This is quite lengthy viewing but worth every wonderful minute.

7. If you are in a room full of people and you can’t tell which one is the jackass –then it is probably you. (This I stole from my big brother @iAndyThompson – but it’s OK to steal…steal like an artist.)

8. Remember to ask yourself – What is the worst case scenario? 
Sometimes it happens as an afterthought but do try to use this idea in the moment. Right now, at this moment…what really is the worst thing that could happen? It doesn’t bear thinking about and in truth, it will never be that bad. So go on, feel the fear and do it anyway.
I’m going to remind myself of that when I feel a bit shy about pressing PUBLISH.

9. You can Google the answer to anything – and so can everyone else.
Except I tried to find a picture of the hangar at Fightertown, Miramar (the one with the lat/long coordinate plaque above the door) but I couldn’t find one…not even on google.

10. If you make a reference to Top Gun, be prepared for the kids to stare back blankly. Remember that 1986 was nearly thirty years ago and move on.

Come on, your turn…anything to add?

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